MEDICARE: MAURA JEAN LOFARO M.D.

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	5889A	WY
2	207VG0400X	Gynecology Physician	5889A	WY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1669423273
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAURA JEAN LOFARO M.D.

Provider Business Mailing Address
First Line	:	PO BOX 1844
Second Line	:
City	:	JACKSON
State	:	WY
Zip	:	83001-1844
Country	:	US
Telephone Number	:	307-734-1005
Fax Number	:	307-734-1165

Provider Business Practice Location Address
First Line	:	555 E BROADWAY AVE
Second Line	:	SUITE 108
City	:	JACKSON
State	:	WY
Zip	:	83001-8640
Country	:	US
Telephone Number	:	307-734-1005
Fax Number	:	307-734-1165

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

Provider Enumeration Date	:	05/16/2006
Last Update Date	:	05/29/2015

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