Provider Demographics
NPI:1811029036
Name:BOFILL, LORA L (MD)
Entity Type:Individual
Prefix:
First Name:LORA
Middle Name:L
Last Name:BOFILL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 E PARHAM RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23228-3118
Mailing Address - Country:US
Mailing Address - Phone:804-264-7808
Mailing Address - Fax:804-346-3191
Practice Address - Street 1:2300 E PARHAM RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23228-3118
Practice Address - Country:US
Practice Address - Phone:804-264-7808
Practice Address - Fax:804-346-3191
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-089017207Q00000X
VA0101243895207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP2746050Medicaid
OHP2746050Medicaid