Provider Demographics
NPI:1033107925
Name:MICHELSON, LORELLE (MD)
Entity Type:Individual
Prefix:
First Name:LORELLE
Middle Name:
Last Name:MICHELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:776 NORTHFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-1102
Mailing Address - Country:US
Mailing Address - Phone:201-487-7227
Mailing Address - Fax:201-487-9293
Practice Address - Street 1:776 NORTHFIELD AVE
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-1102
Practice Address - Country:US
Practice Address - Phone:973-324-2300
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY25MA04066500208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ405250Medicare ID - Type Unspecified
C54131Medicare UPIN