MEDICARE: LORI FUQUA MD

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	207Q00000X	Family Medicine Physician	01036109A	IN

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

General Provider Information

NPI Number	:	1215918867
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORI FUQUA MD

Provider Business Mailing Address
First Line	:	3277 LIBERTY BLVD # A
Second Line	:
City	:	BOONVILLE
State	:	IN
Zip	:	47601-9659
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3277 LIBERTY BLVD # A
Second Line	:
City	:	BOONVILLE
State	:	IN
Zip	:	47601-9659
Country	:	US
Telephone Number	:	812-897-8500
Fax Number	:

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

Provider Enumeration Date	:	11/10/2005
Last Update Date	:	10/05/2022

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