Provider Demographics
NPI:1538129481
Name:CORNELIUS, LISA (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:CORNELIUS
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 1:1100 W 49TH ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78756-3101
Mailing Address - Country:US
Mailing Address - Phone:512-776-6309
Mailing Address - Fax:
Practice Address - Street 1:1100 W 49TH ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756-3101
Practice Address - Country:US
Practice Address - Phone:512-776-6309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6844207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8J0636OtherBLUE SHIELD
TX159620703Medicaid
TX1596207-01Medicaid
TX1596207-02OtherCSHCN
TXP00047686OtherRR/MEDICARE
TX159620703Medicaid
TX1596207-02OtherCSHCN
TXH20309Medicare UPIN