1386936482 NPI number — LORENA SEPSAKOS M.D

Table of content: LORENA SEPSAKOS M.D (NPI 1386936482)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386936482 NPI number — LORENA SEPSAKOS M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SEPSAKOS
Provider First Name:
LORENA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D
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:
1386936482
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1945 CEI DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLUE ASH
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45242-5664
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-984-5133
Provider Business Mailing Address Fax Number:
513-569-3941

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19441 GOLF VISTA PLZ STE 320
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LANSDOWNE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20176-8272
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-858-9800
Provider Business Practice Location Address Fax Number:
703-858-9801
Provider Enumeration Date:
05/06/2011

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: 207W00000X , with the licence number:  0101260784 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0130797 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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