Provider Demographics
NPI:1720403371
Name:DOCTORMOM,MD PEDIATRICS PLLC
Entity Type:Organization
Organization Name:DOCTORMOM,MD PEDIATRICS PLLC
Other - Org Name:DR. LISA HERRIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHYSICAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:J
Authorized Official - Last Name:HERRIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-426-0757
Mailing Address - Street 1:712 SW WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-5711
Mailing Address - Country:US
Mailing Address - Phone:817-426-0757
Mailing Address - Fax:817-426-4109
Practice Address - Street 1:712 SW WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-5711
Practice Address - Country:US
Practice Address - Phone:817-426-0757
Practice Address - Fax:817-426-4109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-19
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH4400261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care