Provider Demographics
NPI:1023145125
Name:MOYERS, LORI A (DO)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:A
Last Name:MOYERS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:A
Other - Last Name:FERGUSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3129 BLATTNER DR
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-6364
Mailing Address - Country:US
Mailing Address - Phone:573-335-0166
Mailing Address - Fax:573-335-7942
Practice Address - Street 1:3129 BLATTNER DR
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-6364
Practice Address - Country:US
Practice Address - Phone:573-335-0166
Practice Address - Fax:573-335-7942
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO115256207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MODA4814OtherRAILROAD MEDICARE
MO245290408Medicaid