Provider Demographics
NPI:1659479475
Name:POELSTRA, LORI LYNN (MD)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:LYNN
Last Name:POELSTRA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:LYNN
Other - Last Name:KELLOGG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:10582 HARVEST GREEN WAY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89135-1240
Mailing Address - Country:US
Mailing Address - Phone:850-797-6180
Mailing Address - Fax:
Practice Address - Street 1:155 CRYSTAL BEACH DR STE 200
Practice Address - Street 2:STE 200
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-3588
Practice Address - Country:US
Practice Address - Phone:850-460-2350
Practice Address - Fax:850-460-2351
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD428100207L00000X
MDD0067850207L00000X
FLME105451207L00000X, 207XS0117X, 208VP0000X, 208VP0014X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD415597100Medicaid
FL001555800Medicaid
FL146PLOtherBLUE CROSS BLUE SHIELD
MDP00684142Medicare PIN
FLCR484XMedicare PIN
FLCR484ZMedicare PIN
MD130874ZACHMedicare PIN