MEDICARE: LORA OVERTON DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	02001611A	IN

General Provider Information

NPI Number	:	1255332664
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORA OVERTON DO

Provider Business Mailing Address
First Line	:	2001 N GRANVILLE AVE
Second Line	:
City	:	MUNCIE
State	:	IN
Zip	:	47303-2110
Country	:	US
Telephone Number	:	765-213-3238
Fax Number	:	765-284-2434

Provider Business Practice Location Address
First Line	:	3217 LAKE AVE
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-5427
Country	:	US
Telephone Number	:	260-490-1524
Fax Number	:	765-284-2434

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	09/18/2012

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