Provider Demographics
NPI:1588656102
Name:FULGENZI, KATHLEEN M (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:FULGENZI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:43800 GARFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1136
Mailing Address - Country:US
Mailing Address - Phone:586-777-2050
Mailing Address - Fax:586-777-2189
Practice Address - Street 1:24911 LITTLE MACK AVE
Practice Address - Street 2:
Practice Address - City:ST CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-3200
Practice Address - Country:US
Practice Address - Phone:586-777-2050
Practice Address - Fax:586-777-2189
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301042670207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4420765Medicaid
MI0Q262160OtherBLUE CROSS
MI4420765Medicaid
M71670052Medicare ID - Type Unspecified