Provider Demographics
NPI:1902899891
Name:LYZAK, JUDY S (MD)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:S
Last Name:LYZAK
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 1:113 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-3301
Mailing Address - Country:US
Mailing Address - Phone:219-873-3130
Mailing Address - Fax:219-873-3132
Practice Address - Street 1:1201 S MAIN ST
Practice Address - Street 2:ST ANTHONY MEDICAL CENTER
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-8481
Practice Address - Country:US
Practice Address - Phone:219-757-6322
Practice Address - Fax:219-757-5891
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01045230A207ZP0102X
IL036087853207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN351173213OtherHFN
IN351173213OtherISPAT/INLAND
IN000000646932OtherANTHEM BC/BS
IL01630255OtherBC/BS
IN351173213OtherSAGAMORE
IN82432OtherBC/BS
INP00829245OtherRAILROAD MEDICARE
IN5197928OtherCCN
IN8352593005OtherCIGNA
IN200124880AMedicaid
IN351173213OtherISPAT/INLAND
IN482210QMedicare PIN
IN000000646932OtherANTHEM BC/BS
IN200124880AMedicaid