Healthcare Provider Details

I. General information

NPI: 1902005689
Provider Name (Legal Business Name): LORA FULP EFAW MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1807 OLD OCILLA RD
TIFTON GA
31794-1617
US

IV. Provider business mailing address

1807 OLD OCILLA RD
TIFTON GA
31794-1617
US

V. Phone/Fax

Practice location:
  • Phone: 229-388-9393
  • Fax: 229-388-9855
Mailing address:
  • Phone: 229-388-9393
  • Fax: 229-388-9855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036727
License Number StateGA

VIII. Authorized Official

Name: MRS. LORA EFAW
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 229-388-9393