Provider Demographics
NPI:1467414227
Name:MULLALLY, LORETTA A (MD)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:A
Last Name:MULLALLY
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 1:5525 E PECK RD
Mailing Address - Street 2:
Mailing Address - City:CROSWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48422
Mailing Address - Country:US
Mailing Address - Phone:810-679-2950
Mailing Address - Fax:810-679-2960
Practice Address - Street 1:5525 E PECK RD
Practice Address - Street 2:
Practice Address - City:CROSWELL
Practice Address - State:MI
Practice Address - Zip Code:48422
Practice Address - Country:US
Practice Address - Phone:810-679-2950
Practice Address - Fax:810-679-2960
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MILM051024208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
0762000OtherBCBSM
MI2684076Medicaid
MI0762000Medicare PIN
MI2684076Medicaid