Provider Demographics
NPI:1306897186
Name:MOTT, LORREN CHARLES (MD)
Entity type:Individual
Prefix:
First Name:LORREN
Middle Name:CHARLES
Last Name:MOTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3915
Mailing Address - Country:US
Mailing Address - Phone:817-334-2800
Mailing Address - Fax:817-820-0094
Practice Address - Street 1:920 HILLTOP DR
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-5488
Practice Address - Country:US
Practice Address - Phone:817-334-2800
Practice Address - Fax:817-820-0094
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ5187207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1288961-01Medicaid
TX1288961-02Medicaid
TX10053015OtherAMERIGROUP
TX1288961-02Medicaid
5840600OtherAETNA PROVIDER ID
TX1288961-02Medicaid
TX060059847Medicare PIN
5840600OtherAETNA PROVIDER ID
TX86475KMedicare PIN
G71093Medicare UPIN