Provider Demographics
NPI:1477583151
Name:LIZAMA, ELMER J
Entity Type:Individual
Prefix:DR
First Name:ELMER
Middle Name:J
Last Name:LIZAMA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10226 DEERMONT TRL
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-2525
Mailing Address - Country:US
Mailing Address - Phone:972-644-6398
Mailing Address - Fax:
Practice Address - Street 1:8059 SCYENE CIR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75227-5534
Practice Address - Country:US
Practice Address - Phone:800-257-8715
Practice Address - Fax:800-819-1655
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22747103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX116012904Medicaid
TX680007553OtherRAIL ROAD
TX116012902Medicaid
TX116012903Medicaid
TX86075AOtherBLUE CROSS BLUE SHIELD
TX116012904Medicaid
TX116012903Medicaid
TX86075AOtherBLUE CROSS BLUE SHIELD