Provider Demographics
NPI:1841292182
Name:LOTZ, LAURENCE H (MD)
Entity type:Individual
Prefix:
First Name:LAURENCE
Middle Name:H
Last Name:LOTZ
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 1:1250 PEACH ST
Mailing Address - Street 2:STE A
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2871
Mailing Address - Country:US
Mailing Address - Phone:805-596-0900
Mailing Address - Fax:805-596-0945
Practice Address - Street 1:1250 PEACH ST
Practice Address - Street 2:STE A
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2871
Practice Address - Country:US
Practice Address - Phone:805-596-0900
Practice Address - Fax:805-596-0945
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC38426207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C384260Medicaid
CA00C384260OtherBLUE SHIELD OF CA PIN
4122978OtherAETNA PIN
724593OtherFIRST HEALTH PIN
CA00C384260Medicaid
080187433Medicare PIN
CAA36926Medicare UPIN