Provider Demographics
NPI:1174147342
Name:HIATT, LINCOLN DAVID (MD)
Entity type:Individual
Prefix:
First Name:LINCOLN
Middle Name:DAVID
Last Name:HIATT
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 1:590 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SNOWFLAKE
Mailing Address - State:AZ
Mailing Address - Zip Code:85937-5228
Mailing Address - Country:US
Mailing Address - Phone:928-536-7519
Mailing Address - Fax:928-536-7305
Practice Address - Street 1:590 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SNOWFLAKE
Practice Address - State:AZ
Practice Address - Zip Code:85937-5228
Practice Address - Country:US
Practice Address - Phone:928-536-7519
Practice Address - Fax:928-536-7305
Is Sole Proprietor?:No
Enumeration Date:2020-06-03
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019032609207Q00000X
NMRS2021-0546390200000X
AZ70370207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program