Provider Demographics
NPI:1861462012
Name:MULLALLY, LISA DENISE (DO)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DENISE
Last Name:MULLALLY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:DENISE
Other - Last Name:NOVAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 108
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46308-0108
Mailing Address - Country:US
Mailing Address - Phone:219-779-8735
Mailing Address - Fax:877-715-2312
Practice Address - Street 1:11275 DELAWARE PKWY
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-7812
Practice Address - Country:US
Practice Address - Phone:219-779-8735
Practice Address - Fax:877-715-2312
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02003098207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200833870Medicaid
IN000000721919OtherANTHEM TRADITIONAL
IN200833870Medicaid
IN202790JJJMedicare PIN
INM400049699Medicare PIN
IN000000721919OtherANTHEM TRADITIONAL
MI0B56065017Medicare UPIN