Provider Demographics
NPI:1376582734
Name:COLYER-AVERSA, LORI ANN (MD)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:ANN
Last Name:COLYER-AVERSA
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:LB 7550 PO BOX 95000
Mailing Address - Street 2:
Mailing Address - City:PHILADEPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19195-7550
Mailing Address - Country:US
Mailing Address - Phone:844-362-1735
Mailing Address - Fax:973-290-7495
Practice Address - Street 1:399 HOOVER AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-3924
Practice Address - Country:US
Practice Address - Phone:973-748-9500
Practice Address - Fax:973-748-9492
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA58011208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5553903-01Medicaid
NJF51606Medicare UPIN