Provider Demographics
NPI:1417035981
Name:SPORTELLI, LORI ANN (OD)
Entity Type:Individual
Prefix:DR
First Name:LORI
Middle Name:ANN
Last Name:SPORTELLI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 S ELLWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-3951
Mailing Address - Country:US
Mailing Address - Phone:410-284-2352
Mailing Address - Fax:410-284-3796
Practice Address - Street 1:8201 PHILADELPHIA RD
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:MD
Practice Address - Zip Code:21237-2832
Practice Address - Country:US
Practice Address - Phone:410-866-2022
Practice Address - Fax:410-866-2031
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1569152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD401431600Medicaid
MD308RMedicare ID - Type Unspecified
U59360Medicare UPIN