MEDICARE: LISA DENISE MULLALLY D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	02003098	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	000000721919	OTHER	IN	ANTHEM TRADITIONAL

General Provider Information

NPI Number	:	1861462012
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA DENISE MULLALLY D.O.

Provider Business Mailing Address
First Line	:	PO BOX 108
Second Line	:
City	:	CROWN POINT
State	:	IN
Zip	:	46308-0108
Country	:	US
Telephone Number	:	219-779-8735
Fax Number	:	877-715-2312

Provider Business Practice Location Address
First Line	:	11275 DELAWARE PKWY
Second Line	:
City	:	CROWN POINT
State	:	IN
Zip	:	46307-7812
Country	:	US
Telephone Number	:	219-779-8735
Fax Number	:	877-715-2312

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/23/2006
Last Update Date	:	03/25/2019

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