Provider Demographics
NPI:1144339920
Name:GAGNON, LORI I (MD)
Entity type:Individual
Prefix:DR
First Name:LORI
Middle Name:I
Last Name:GAGNON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:I
Other - Last Name:BRAVEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4330 MEDICAL DR
Mailing Address - Street 2:STE 500
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3318
Mailing Address - Country:US
Mailing Address - Phone:210-426-6230
Mailing Address - Fax:210-599-2104
Practice Address - Street 1:4330 MEDICAL DR
Practice Address - Street 2:STE 500
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3318
Practice Address - Country:US
Practice Address - Phone:210-426-6230
Practice Address - Fax:210-599-2104
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM2227207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00375637OtherRR MCR
TX8W5070OtherBLUE CROSS BLUE SHIELD
TX184196701Medicaid
TXP00375637OtherRR MCR
TXH94511Medicare UPIN