Healthcare Provider Details

I. General information

NPI: 1578529822
Provider Name (Legal Business Name): LORI FERTIG CONKLIN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 04/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19219 STATE HWY 198
SAEGERTOWN PA
16433-4529
US

IV. Provider business mailing address

19219 STATE HWY 198
SAEGERTOWN PA
16433-4529
US

V. Phone/Fax

Practice location:
  • Phone: 814-763-5220
  • Fax: 814-763-4425
Mailing address:
  • Phone: 814-763-5220
  • Fax: 814-763-4425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG001633
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: