Provider Demographics
NPI:1467627737
Name:LEZAMA, MAYBELLINE VIRGINIA (MD)
Entity Type:Individual
Prefix:DR
First Name:MAYBELLINE
Middle Name:VIRGINIA
Last Name:LEZAMA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MAYBELLINE
Other - Middle Name:VIRGINIA
Other - Last Name:HERNANDEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-2111
Mailing Address - Fax:
Practice Address - Street 1:1605 S 31ST ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76508-1253
Practice Address - Country:US
Practice Address - Phone:254-215-0100
Practice Address - Fax:254-215-0636
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-28
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN3831207R00000X
CT046899207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine