Provider Demographics
NPI:1912014689
Name:ILLUMINATI, LUISE ANN (MD)
Entity Type:Individual
Prefix:
First Name:LUISE
Middle Name:ANN
Last Name:ILLUMINATI
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 1:3924 SHELLMARR LN
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-4055
Mailing Address - Country:US
Mailing Address - Phone:248-496-2112
Mailing Address - Fax:
Practice Address - Street 1:3924 SHELLMARR LN
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-4055
Practice Address - Country:US
Practice Address - Phone:248-496-2112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2019-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301047490207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
E40216Medicare UPIN