Healthcare Provider Details

I. General information

NPI: 1770573826
Provider Name (Legal Business Name): LORI A SANSONE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 10/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGAR MAPLE DR 88TH MDOS/SGOPC
WPAFB OH
45433-5546
US

IV. Provider business mailing address

4881 SUGAR MAPLE DR 88TH MDOS/SGOPC
WPAFB OH
45433-5546
US

V. Phone/Fax

Practice location:
  • Phone: 937-257-9700
  • Fax:
Mailing address:
  • Phone: 937-257-9700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number035-049165
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: