Provider Demographics
NPI:1497072664
Name:DEFANTI, LUCY ELENA
Entity Type:Individual
Prefix:
First Name:LUCY
Middle Name:ELENA
Last Name:DEFANTI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LUCY
Other - Middle Name:ELENA
Other - Last Name:MAULBETSCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5700 SOUTHWYCK BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-1509
Mailing Address - Country:US
Mailing Address - Phone:800-288-8325
Mailing Address - Fax:
Practice Address - Street 1:500 J CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-1929
Practice Address - Country:US
Practice Address - Phone:757-594-2160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-28
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102204122207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1497072664Medicaid