Provider Demographics
NPI:1295830081
Name:DEFUSCO, LISA MICHELE (MD)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MICHELE
Last Name:DEFUSCO
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 1:1514 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:
Practice Address - Street 1:4901 VETERANS BLVD.
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70001
Practice Address - Country:US
Practice Address - Phone:504-887-1133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.026056208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1050962Medicaid
MS09876251Medicaid
LA4K673Medicare PIN