Provider Demographics
NPI:1972628634
Name:FACKTOR, LORI ANN (OD)
Entity Type:Individual
Prefix:DR
First Name:LORI
Middle Name:ANN
Last Name:FACKTOR
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5765 BURKE CENTRE PKWY STE L
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-2264
Mailing Address - Country:US
Mailing Address - Phone:703-250-2000
Mailing Address - Fax:703-978-9581
Practice Address - Street 1:5765 BURKE CENTRE PKWY STE L
Practice Address - Street 2:
Practice Address - City:BURKE
Practice Address - State:VA
Practice Address - Zip Code:22015-2264
Practice Address - Country:US
Practice Address - Phone:703-250-2000
Practice Address - Fax:703-978-9581
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001148152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
008985O02Medicare PIN