Provider Demographics
NPI:1528045663
Name:SEGRIST, KAREN LORDO (MD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:LORDO
Last Name:SEGRIST
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 1:1310 DADRIAN PROFESSIONAL PARK
Mailing Address - Street 2:
Mailing Address - City:GODFREY
Mailing Address - State:IL
Mailing Address - Zip Code:62035-1685
Mailing Address - Country:US
Mailing Address - Phone:618-433-5005
Mailing Address - Fax:618-467-1053
Practice Address - Street 1:1310 DADRIAN PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035-1685
Practice Address - Country:US
Practice Address - Phone:618-433-5005
Practice Address - Fax:618-467-1053
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036059505207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036059505Medicaid
ILP00072982OtherMEDICARE RR
ILP00072982OtherMEDICARE RR
IL036059505Medicaid
K03683Medicare PIN