Provider Demographics
NPI:1063445559
Name:FUGETT, MARY D (DO)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:D
Last Name:FUGETT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:7905 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2549
Practice Address - Country:US
Practice Address - Phone:219-836-5800
Practice Address - Fax:219-836-3048
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2025-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02007451A207Q00000X
IL36-092047207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL95917OtherPIN
ILL95917OtherPIN
ILG20953Medicare UPIN