Provider Demographics
NPI:1578658654
Name:GORE-GREEN, LORI (DO)
Entity Type:Individual
Prefix:DR
First Name:LORI
Middle Name:
Last Name:GORE-GREEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9524 E 81ST ST
Mailing Address - Street 2:STE. B-1588
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-8032
Mailing Address - Country:US
Mailing Address - Phone:918-740-2026
Mailing Address - Fax:918-893-1260
Practice Address - Street 1:717 S HOUSTON AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74127-9023
Practice Address - Country:US
Practice Address - Phone:918-740-2026
Practice Address - Fax:918-893-1260
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101012247207V00000X
OK3325207VG0400X
TXK7545207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX115218401Medicaid
TX00524UMedicare ID - Type Unspecified
TX115218401Medicaid
TX8A2108Medicare PIN