Provider Demographics
NPI:1336106046
Name:SHEPORAITIS, LORI A (MD)
Entity Type:Individual
Prefix:DR
First Name:LORI
Middle Name:A
Last Name:SHEPORAITIS
Suffix:
Gender:F
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:PO BOX 2007
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-4507
Mailing Address - Country:US
Mailing Address - Phone:315-362-5285
Mailing Address - Fax:
Practice Address - Street 1:762 ROUTE 3
Practice Address - Street 2:SUITE 14
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-7472
Practice Address - Country:US
Practice Address - Phone:518-562-3204
Practice Address - Fax:518-563-0707
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2020-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY21056042085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01827807Medicaid
G71763Medicare UPIN
NY01827807Medicaid