Provider Demographics
NPI:1003923756
Name:ROUTH, LISA CAROLE (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:CAROLE
Last Name:ROUTH
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:PO BOX 1808
Mailing Address - Street 2:
Mailing Address - City:FRIENDSWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77549-1808
Mailing Address - Country:US
Mailing Address - Phone:281-400-3301
Mailing Address - Fax:281-400-3307
Practice Address - Street 1:341 E PARKWOOD AVE
Practice Address - Street 2:
Practice Address - City:FRIENDSWOOD
Practice Address - State:TX
Practice Address - Zip Code:77546-5147
Practice Address - Country:US
Practice Address - Phone:281-400-3301
Practice Address - Fax:281-400-3307
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH2742174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX098513703Medicaid
TX200379218OtherTAX ID
TX098513703Medicaid
TX610702Medicare ID - Type UnspecifiedMEDICARE