Provider Demographics
NPI:1295727352
Name:DEPERSIA, LORI A (MD)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:A
Last Name:DEPERSIA
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 1:1001 BRIGGS RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-4100
Mailing Address - Country:US
Mailing Address - Phone:856-231-4774
Mailing Address - Fax:856-231-9699
Practice Address - Street 1:1648 HUNTINGDON PIKE
Practice Address - Street 2:RADIOLOGY DEPARTMENT
Practice Address - City:MEADOWBROOK
Practice Address - State:PA
Practice Address - Zip Code:19046-8001
Practice Address - Country:US
Practice Address - Phone:215-938-3467
Practice Address - Fax:215-938-3474
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD029084E2085R0202X, 2085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0073256900006Medicaid
PA007325269Medicaid
NJ2210703Medicaid
PA0073256900006Medicaid
NJ2210703Medicaid
NJ462097Medicare ID - Type Unspecified