Provider Demographics
NPI:1336177674
Name:DESTEFANO, LISA ANN (DO)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANN
Last Name:DESTEFANO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:VREDEVOOGD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:804 SERVICE RD STE A109B
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-432-6144
Mailing Address - Fax:517-432-6150
Practice Address - Street 1:4660 S HAGADORN RD STE 500
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-6804
Practice Address - Country:US
Practice Address - Phone:517-432-6144
Practice Address - Fax:517-432-6150
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012158204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3346153Medicaid
MIC36088047Medicare PIN
MIG52748Medicare UPIN