Provider Demographics
NPI:1962475236
Name:FULGENZI, LISA ANNE (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANNE
Last Name:FULGENZI
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 1:26711 WOODWARD AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48070
Mailing Address - Country:US
Mailing Address - Phone:248-543-6000
Mailing Address - Fax:248-543-3770
Practice Address - Street 1:26711 WOODWARD AVE STE 103
Practice Address - Street 2:
Practice Address - City:HUNTINGTON WOODS
Practice Address - State:MI
Practice Address - Zip Code:48070
Practice Address - Country:US
Practice Address - Phone:248-543-6000
Practice Address - Fax:248-543-3770
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MILF054789207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI443604010Medicaid
MI443604010Medicaid
F70288Medicare UPIN