Provider Demographics
NPI:1336102169
Name:LUCARELLI, MELISSA ELAINE (MD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ELAINE
Last Name:LUCARELLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 S HIGH ST
Mailing Address - Street 2:PO BOX 101
Mailing Address - City:RANDOLPH
Mailing Address - State:WI
Mailing Address - Zip Code:53956-1499
Mailing Address - Country:US
Mailing Address - Phone:920-326-5060
Mailing Address - Fax:920-326-5061
Practice Address - Street 1:504 S HIGH STREET
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:WI
Practice Address - Zip Code:53956
Practice Address - Country:US
Practice Address - Phone:920-326-5060
Practice Address - Fax:920-326-5061
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36988020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080174465OtherRAILROAD MEDICARE
WI11573OtherDEAN HEALTH PLAN
WI32327000Medicaid
080174465OtherRAILROAD MEDICARE
WI11573OtherDEAN HEALTH PLAN