Provider Demographics
NPI:1730173691
Name:LOTMAN, ANTON ERIKOVICH (MD)
Entity type:Individual
Prefix:DR
First Name:ANTON
Middle Name:ERIKOVICH
Last Name:LOTMAN
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 1:1900 WOODLAND DRIVE
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-0000
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:541-266-4553
Practice Address - Street 1:1900 WOODLAND DRIVE
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-0000
Practice Address - Country:US
Practice Address - Phone:541-267-5151
Practice Address - Fax:541-266-4553
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR261342084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR930802343OtherTAX ID#
OR930635514OtherTAX ID
OR026822Medicaid
ORR0000WFBTVOtherMEDICARE GROUP PIN
OR1407812365OtherMEDICARE GROUP NPI
OR930802343OtherTAX ID#
ORR0000WFBTVOtherMEDICARE GROUP PIN
OR0577260001Medicare NSC
ORR000WCKDHMedicare PIN