Provider Demographics
NPI:1871552497
Name:MANZ DULAC, LISA ALLYN (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:ALLYN
Last Name:MANZ DULAC
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 1:20030 MACK AVE
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236
Mailing Address - Country:US
Mailing Address - Phone:313-884-3380
Mailing Address - Fax:313-884-9756
Practice Address - Street 1:20030 MACK AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-2323
Practice Address - Country:US
Practice Address - Phone:313-884-3380
Practice Address - Fax:313-884-9756
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010053049174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3491350Medicaid
MIE92635Medicare UPIN
MI3491350Medicaid