Provider Demographics
NPI:1932191400
Name:BLAIR-BRITT, LORAY ANTOINETTE (MD)
Entity Type:Individual
Prefix:MS
First Name:LORAY
Middle Name:ANTOINETTE
Last Name:BLAIR-BRITT
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 1:1410 LPGA BLVD, STE 136
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5146
Mailing Address - Country:US
Mailing Address - Phone:386-274-4750
Mailing Address - Fax:386-274-4756
Practice Address - Street 1:1410 LPGA BLVD, STE 136
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5146
Practice Address - Country:US
Practice Address - Phone:386-274-4750
Practice Address - Fax:386-274-4757
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME60233207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL058163100Medicaid
FLE49167Medicare UPIN
FL12681Medicare ID - Type Unspecified