Healthcare Provider Details

I. General information

NPI: 1417057456
Provider Name (Legal Business Name): LISA KUTAS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 10/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5333 MCAULEY DR 6109
YPSILANTI MI
48197-1014
US

IV. Provider business mailing address

24 FRANK LLOYD WRIGHT DR PO BOX 0446 LOBBY J
ANN ARBOR MI
48105-9484
US

V. Phone/Fax

Practice location:
  • Phone: 734-712-1300
  • Fax: 734-712-1330
Mailing address:
  • Phone: 734-747-6766
  • Fax: 734-747-8605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301081281
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: