=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497180830
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN RICHARD LOTTES PT, DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2013
-----------------------------------------------------
Last Update Date | 09/04/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 WALT WHITMAN RD SUITE 310
-----------------------------------------------------
City | MELVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11747-2293
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-923-2288
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 128 BROOKVILLE RD
-----------------------------------------------------
City | GLEN HEAD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11545-3306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-626-6632
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 036718
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------