Provider Demographics
NPI:1508142050
Name:EREIFEJ, LISA KHALIL (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:KHALIL
Last Name:EREIFEJ
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 1:6701 JEFFERSON ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4318
Mailing Address - Country:US
Mailing Address - Phone:505-727-6200
Mailing Address - Fax:
Practice Address - Street 1:6701 JEFFERSON ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109
Practice Address - Country:US
Practice Address - Phone:505-727-6200
Practice Address - Fax:505-727-9590
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-28
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM282N00000X
NMMD2017-0615207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM75250080Medicaid