Provider Demographics
NPI:1982795456
Name:FUGATE, LISA P (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:P
Last Name:FUGATE
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 1:700 ACKERMAN RD STE 385
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1524
Mailing Address - Country:US
Mailing Address - Phone:614-947-3700
Mailing Address - Fax:614-947-3771
Practice Address - Street 1:480 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210
Practice Address - Country:US
Practice Address - Phone:614-293-7604
Practice Address - Fax:614-293-3809
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35062775F208100000X
OH35.06.27552081P0004X
OH35.06.27752083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P0004XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSpinal Cord Injury Medicine
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2025418Medicaid
OH2025418Medicaid
OH0815481Medicare PIN