Provider Demographics
NPI:1770543381
Name:REDDICK, LOVETT P (MD)
Entity type:Individual
Prefix:
First Name:LOVETT
Middle Name:P
Last Name:REDDICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2008 BROOKSIDE DRIVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660
Mailing Address - Country:US
Mailing Address - Phone:423-247-8104
Mailing Address - Fax:423-247-9732
Practice Address - Street 1:2008 BROOKSIDE DR
Practice Address - Street 2:SUITE 202
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4640
Practice Address - Country:US
Practice Address - Phone:423-247-8104
Practice Address - Fax:423-247-9732
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD11963208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
B04004Medicare UPIN
3383216Medicare ID - Type Unspecified