Provider Demographics
NPI:1821046277
Name:FANTRY, LORI E (MD, MPH)
Entity Type:Individual
Prefix:DR
First Name:LORI
Middle Name:E
Last Name:FANTRY
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 245039
Mailing Address - Street 2:1501 N. CAMPBELL AVE.
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85722
Mailing Address - Country:US
Mailing Address - Phone:520-626-6887
Mailing Address - Fax:520-626-5183
Practice Address - Street 1:1501 N CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85724-1544
Practice Address - Country:US
Practice Address - Phone:410-328-9105
Practice Address - Fax:410-328-4430
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ52406207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC4420540Medicaid
MD520948-01 & 02OtherBLUE CROSS/BLUE SHIELD
MD066631900Medicaid
MDP01027245Medicare PIN
MD066631900Medicaid
MDS033313UMedicare PIN