Provider Demographics
NPI:1649566829
Name:FREETAGE, LORI MICHELE (DO)
Entity Type:Individual
Prefix:DR
First Name:LORI
Middle Name:MICHELE
Last Name:FREETAGE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:LORI
Other - Middle Name:MICHELE
Other - Last Name:HENER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:3451 NEWMARK DR
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-5426
Mailing Address - Country:US
Mailing Address - Phone:201-741-8875
Mailing Address - Fax:
Practice Address - Street 1:3535 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45429-1221
Practice Address - Country:US
Practice Address - Phone:201-741-8875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-25
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS166272085R0202X
OH34.0142662085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN