Provider Demographics
NPI:1861417065
Name:LOTT, ROGER T (MD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:T
Last Name:LOTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-649-2775
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:2313 HIGHWAY 15 N
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-1805
Practice Address - Country:US
Practice Address - Phone:601-649-2775
Practice Address - Fax:601-649-2686
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15957207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1554197Medicaid
MS00120367Medicaid
G48727Medicare UPIN
LA1554197Medicaid
MS930001209Medicare ID - Type UnspecifiedER