Basic Information
| Provider Information | |||||||||
| NPI: | 1144216508 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEBLASI | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 730 GOODLETTE RD | ||||||||
| Address2: | STE 102 | ||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341025617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2394303668 | ||||||||
| FaxNumber: | 2396929436 | ||||||||
| Practice Location | |||||||||
| Address1: | 1645 COLONIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339071101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2394303668 | ||||||||
| FaxNumber: | 2396929436 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 09/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 09/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0131X | 4222 | FL | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery |
ID Information
| ID | Type | State | Issuer | Description | PD6416 | 05 | SC | MEDICAID | 10790442 | 01 | OH | CAQH | OTHER | 2215481 | 05 | OH | MEDICAID | 641 | 01 | SC | SC MEDICAL LICENSE | OTHER |