Provider Demographics
NPI:1437132628
Name:PROCTOR, LORI MARIE (DPM)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:MARIE
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3885 MECHANICSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:PA
Mailing Address - Zip Code:18052-3321
Mailing Address - Country:US
Mailing Address - Phone:610-437-9343
Mailing Address - Fax:610-437-5997
Practice Address - Street 1:3885 MECHANICSVILLE RD
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:PA
Practice Address - Zip Code:18052-3321
Practice Address - Country:US
Practice Address - Phone:610-437-9343
Practice Address - Fax:610-437-5997
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-22
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003287L213E00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA428757OtherMEDICARE PTAN
PA1810101OtherCAPITOL BLUE CROSS
PA122132OtherTHREE RIVERS
PA001133549Medicaid
PA1519638OtherGATEWAY
4376770001Medicare NSC
PA428757Medicare ID - Type Unspecified
PAT30379Medicare UPIN