Provider Demographics
NPI:1467679076
Name:MAGOULAS, LORI A (PHD, RD)
Entity Type:Individual
Prefix:DR
First Name:LORI
Middle Name:A
Last Name:MAGOULAS
Suffix:
Gender:F
Credentials:PHD, RD
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 7925
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:07702-7925
Mailing Address - Country:US
Mailing Address - Phone:732-544-1661
Mailing Address - Fax:732-544-9022
Practice Address - Street 1:39 AVENUE AT THE COMMON
Practice Address - Street 2:SUITE 106
Practice Address - City:SHREWSBURY
Practice Address - State:NJ
Practice Address - Zip Code:07702
Practice Address - Country:US
Practice Address - Phone:732-544-1661
Practice Address - Fax:732-544-9022
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
NJ705971133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ942955OtherAETNA PROVIDER ID
NJP2970225OtherPROVIDER ID NUMBER