Provider Demographics
NPI:1578529822
Name:CONKLIN, LORI FERTIG (OD)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:FERTIG
Last Name:CONKLIN
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 1:19219 STATE HWY 198
Mailing Address - Street 2:
Mailing Address - City:SAEGERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:16433-4529
Mailing Address - Country:US
Mailing Address - Phone:814-763-5220
Mailing Address - Fax:814-763-4425
Practice Address - Street 1:19219 STATE HWY 198
Practice Address - Street 2:
Practice Address - City:SAEGERTOWN
Practice Address - State:PA
Practice Address - Zip Code:16433-4529
Practice Address - Country:US
Practice Address - Phone:814-763-5220
Practice Address - Fax:814-763-4425
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001633152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAME735137Medicare ID - Type Unspecified
PAU33160Medicare UPIN