Provider Demographics
NPI:1275724841
Name:CEBALLOS, LAURA LISA (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:LISA
Last Name:CEBALLOS
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 1:95 E PRICE RD
Mailing Address - Street 2:BLDG A
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78521-3531
Mailing Address - Country:US
Mailing Address - Phone:956-544-2001
Mailing Address - Fax:
Practice Address - Street 1:1076 E LOS EBANOS BLVD
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78520-9988
Practice Address - Country:US
Practice Address - Phone:956-544-2001
Practice Address - Fax:956-546-4567
Is Sole Proprietor?:No
Enumeration Date:2007-08-07
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM8580207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX201438301Medicaid
8CA111OtherBCBS
TXM8580OtherLIC