Provider Demographics
NPI:1710998232
Name:GAMBLE, LISA LYNELLE (MD)
Entity Type:Individual
Prefix:MISS
First Name:LISA
Middle Name:LYNELLE
Last Name:GAMBLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:BROCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6400
Mailing Address - Fax:
Practice Address - Street 1:800 E DAWSON ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2036
Practice Address - Country:US
Practice Address - Phone:903-525-1914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2017-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA23658207RC0200X, 207RP1001X
TXQ0047207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX752616977042OtherTRICARE
MS09050308Medicaid
TX369671801Medicaid
LA1484164Medicaid
TX8GM927OtherBCBS
TXP01831137OtherMEDICARE RAIL ROAD
H62709Medicare UPIN
LA1484164Medicaid
MS09050308Medicaid
TXP01831137OtherMEDICARE RAIL ROAD