Healthcare Provider Details

I. General information

NPI: 1174147342
Provider Name (Legal Business Name): LINCOLN DAVID HIATT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2020
Last Update Date: 08/05/2024
Certification Date: 08/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 S MAIN ST
SNOWFLAKE AZ
85937-5228
US

IV. Provider business mailing address

590 S MAIN ST
SNOWFLAKE AZ
85937-5228
US

V. Phone/Fax

Practice location:
  • Phone: 928-536-7519
  • Fax: 928-536-7305
Mailing address:
  • Phone: 928-536-7519
  • Fax: 928-536-7305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2019032609
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRS2021-0546
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number70370
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: