Provider Demographics
NPI:1720161425
Name:SUMMERLIN, LORRAINE DEANGELIS (O D)
Entity Type:Individual
Prefix:DR
First Name:LORRAINE
Middle Name:DEANGELIS
Last Name:SUMMERLIN
Suffix:
Gender:F
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5447 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GRANT
Mailing Address - State:AL
Mailing Address - Zip Code:35747-8322
Mailing Address - Country:US
Mailing Address - Phone:256-728-3937
Mailing Address - Fax:
Practice Address - Street 1:5447 MAIN ST
Practice Address - Street 2:
Practice Address - City:GRANT
Practice Address - State:AL
Practice Address - Zip Code:35747-8322
Practice Address - Country:US
Practice Address - Phone:256-728-3937
Practice Address - Fax:256-728-3938
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS969TA526152W00000X
GAOPT001876152W00000X
TNOD0000002212152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL99005Medicare ID - Type Unspecified
ALU82873Medicare UPIN