Healthcare Provider Details

I. General information

NPI: 1639198179
Provider Name (Legal Business Name): LORI JEAN DOTSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 11/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

965 S BAILEY AVE
SOUTH HAVEN MI
49090-6743
US

IV. Provider business mailing address

965 S BAILEY AVE
SOUTH HAVEN MI
49090-6743
US

V. Phone/Fax

Practice location:
  • Phone: 269-639-2833
  • Fax: 269-639-2776
Mailing address:
  • Phone: 269-639-2833
  • Fax: 269-639-2776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301074647
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: