Provider Demographics
NPI:1174752067
Name:HERBST, LORI A (MD)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:A
Last Name:HERBST
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:A
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3333 BURNET AVE.
Mailing Address - Street 2:MLC9016
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229
Mailing Address - Country:US
Mailing Address - Phone:513-803-8092
Mailing Address - Fax:513-803-9245
Practice Address - Street 1:3333 BURNET AVE.
Practice Address - Street 2:MLC9016
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229
Practice Address - Country:US
Practice Address - Phone:513-803-8092
Practice Address - Fax:513-803-9245
Is Sole Proprietor?:No
Enumeration Date:2009-07-13
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.123419207RH0002X, 208000000X
OH35-123419207RH0002X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0104080Medicaid
KY7100305360Medicaid
IN201233460Medicaid