Provider Demographics
NPI:1265477830
Name:HRUZA, LUCIANN LISI (MD)
Entity Type:Individual
Prefix:
First Name:LUCIANN
Middle Name:LISI
Last Name:HRUZA
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 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:816 S KIRKWOOD RD STE 210
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-6056
Practice Address - Country:US
Practice Address - Phone:314-645-4500
Practice Address - Fax:314-645-5907
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD100200207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO001013498Medicare PIN
MOF57539Medicare UPIN