Provider Demographics
NPI:1477555878
Name:BLAIR, LISA JILL (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:JILL
Last Name:BLAIR
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 1:2638 DEBRA LN
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78418-2704
Mailing Address - Country:US
Mailing Address - Phone:830-200-1366
Mailing Address - Fax:
Practice Address - Street 1:1711 W WHEELER AVE
Practice Address - Street 2:
Practice Address - City:ARANSAS PASS
Practice Address - State:TX
Practice Address - Zip Code:78336-4536
Practice Address - Country:US
Practice Address - Phone:361-226-3434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6444207Q00000X
AL23987207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009961480Medicaid
AL051503402Medicare ID - Type UnspecifiedMEDICARE
AL009961480Medicaid