Provider Demographics
NPI:1770511362
Name:CORDOVA, LOREE JC (MD)
Entity Type:Individual
Prefix:DR
First Name:LOREE
Middle Name:JC
Last Name:CORDOVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:LOREE
Other - Middle Name:J
Other - Last Name:COLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3425
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66046-0425
Mailing Address - Country:US
Mailing Address - Phone:785-830-0100
Mailing Address - Fax:785-830-0115
Practice Address - Street 1:4921 W 18TH ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66047-2090
Practice Address - Country:US
Practice Address - Phone:785-830-0100
Practice Address - Fax:785-830-0115
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0429180207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS103231Medicare ID - Type Unspecified
KSH43721Medicare UPIN