Provider Demographics
NPI:1215917745
Name:DOTHAN UROLOGY, PC
Entity type:Organization
Organization Name:DOTHAN UROLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LOIS
Authorized Official - Middle Name:W
Authorized Official - Last Name:SALLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-793-9564
Mailing Address - Street 1:4300 W MAIN ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-1054
Mailing Address - Country:US
Mailing Address - Phone:334-793-9564
Mailing Address - Fax:334-671-8907
Practice Address - Street 1:4300 W MAIN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1054
Practice Address - Country:US
Practice Address - Phone:334-793-9564
Practice Address - Fax:334-671-8907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL=========OtherTRICARE GROUP PROVIDER #
AL=========OtherTRICARE GROUP PROVIDER #