Provider Demographics
NPI:1255332664
Name:OVERTON, LORA (DO)
Entity Type:Individual
Prefix:
First Name:LORA
Middle Name:
Last Name:OVERTON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 N GRANVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-2110
Mailing Address - Country:US
Mailing Address - Phone:765-213-3238
Mailing Address - Fax:765-284-2434
Practice Address - Street 1:3217 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5427
Practice Address - Country:US
Practice Address - Phone:260-490-1524
Practice Address - Fax:765-284-2434
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001611A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F94579Medicare UPIN