Provider Demographics
NPI:1578530374
Name:DISEATI, LORI RENEE (MD)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:RENEE
Last Name:DISEATI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:RENEE
Other - Last Name:WAMPLER-DISEATI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:39TH MEDICAL GROUP
Mailing Address - Street 2:UNIT 7095
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09824-5185
Mailing Address - Country:US
Mailing Address - Phone:202-714-4234
Mailing Address - Fax:
Practice Address - Street 1:39TH MEDICAL GROUP
Practice Address - Street 2:UNIT 7095
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09824-5185
Practice Address - Country:US
Practice Address - Phone:202-714-4234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012316822083P0901X, 207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARVAD000Medicare UPIN