Provider Demographics
NPI:1720031404
Name:FAIRWEATHER, LISA DIANE (DO)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:DIANE
Last Name:FAIRWEATHER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:LISA
Other - Middle Name:DIANE
Other - Last Name:ALLOJU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:5601 BRIDGE ST.
Mailing Address - Street 2:#324
Mailing Address - City:FT. WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112
Mailing Address - Country:US
Mailing Address - Phone:817-457-4646
Mailing Address - Fax:817-492-7135
Practice Address - Street 1:5601 BRIDGE ST.
Practice Address - Street 2:#324
Practice Address - City:FT. WORTH
Practice Address - State:TX
Practice Address - Zip Code:76112
Practice Address - Country:US
Practice Address - Phone:817-457-4646
Practice Address - Fax:817-492-7135
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL62562084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX175470702Medicaid
TX8D9020Medicare ID - Type Unspecified
TX175470702Medicaid