Provider Demographics
NPI:1952354342
Name:MAZZULLO, LISA C (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:C
Last Name:MAZZULLO
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 1:55 W DELAWARE PL
Mailing Address - Street 2:UNIT 907
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-3360
Mailing Address - Country:US
Mailing Address - Phone:312-751-7515
Mailing Address - Fax:312-751-1208
Practice Address - Street 1:737 N MICHIGAN AVE
Practice Address - Street 2:SUITE 950
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2615
Practice Address - Country:US
Practice Address - Phone:312-751-7515
Practice Address - Fax:312-751-1208
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG13879Medicare UPIN