Provider Demographics
NPI:1063445559
Name:FUGETT, MARY D (D)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:D
Last Name:FUGETT
Suffix:
Gender:F
Credentials:D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15300 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-4600
Mailing Address - Country:US
Mailing Address - Phone:708-460-5550
Mailing Address - Fax:708-226-2595
Practice Address - Street 1:15300 WEST AVE
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-4600
Practice Address - Country:US
Practice Address - Phone:708-460-5550
Practice Address - Fax:708-226-2595
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-092047207Q00000X
IN02007451A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL95917OtherPIN
ILL95917OtherPIN
ILG20953Medicare UPIN