Provider Demographics
NPI:1770685372
Name:FARABAUGH, LORI ANNE (OD)
Entity type:Individual
Prefix:DR
First Name:LORI
Middle Name:ANNE
Last Name:FARABAUGH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 DRAKE RD
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:NC
Mailing Address - Zip Code:28443-2550
Mailing Address - Country:US
Mailing Address - Phone:856-495-0031
Mailing Address - Fax:
Practice Address - Street 1:16747 US HIGHWAY 17 N STE 140
Practice Address - Street 2:
Practice Address - City:HAMPSTEAD
Practice Address - State:NC
Practice Address - Zip Code:28443-3086
Practice Address - Country:US
Practice Address - Phone:910-507-2019
Practice Address - Fax:910-363-0342
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG01718152W00000X
NC2149152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2248OtherAETNA HMO
NC1770685372Medicaid
PA2248OtherAETNA HMO