1083752570 NPI number — DR. LORI J CANFIELD OD

Table of content: DR. LORI J CANFIELD OD (NPI 1083752570)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083752570 NPI number — DR. LORI J CANFIELD OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CANFIELD
Provider First Name:
LORI
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083752570
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
317 EAST PARKWAY DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RUSSELLVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72801-3915
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-967-6113
Provider Business Mailing Address Fax Number:
479-968-6932

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
317 EAST PARKWAY DRIVE
Provider Second Line Business Practice Location Address:
DAIBER VISION CARE
Provider Business Practice Location Address City Name:
RUSSELLVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72801-3915
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-967-6113
Provider Business Practice Location Address Fax Number:
479-968-6932
Provider Enumeration Date:
02/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  AR2522 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7069287 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 49790 . This is a "ARKANSAS BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 145334722 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 06020018300 . This is a "QUALCHOICE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: AR2522 . This is a "EYEMED" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: A003 . This is a "TRICARE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: AR0033029 . This is a "HUMANA" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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