Provider Demographics
NPI:1700847779
Name:ABBOTT, LISA A (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:A
Last Name:ABBOTT
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 1:3601 N. HWY 157
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063
Mailing Address - Country:US
Mailing Address - Phone:817-473-7962
Mailing Address - Fax:
Practice Address - Street 1:3601 N. HWY 157
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063
Practice Address - Country:US
Practice Address - Phone:817-473-7962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2859207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH00371Medicare UPIN
TX87002KMedicare ID - Type Unspecified