Provider Demographics
NPI:1750489993
Name:ROTEN, LISA M (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:ROTEN
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:PO BOX 99371
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0371
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-7347
Practice Address - Street 1:1500 COOPER ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2710
Practice Address - Country:US
Practice Address - Phone:682-885-2140
Practice Address - Fax:817-332-2506
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK84622080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1750369203OtherGRP NPI NUMBER
TX1930253OtherUHC PIN
TX119121503Medicaid
TX1729022OtherFIRSTHEALTH PIN
TX00U87ZOtherBCBSTX GRP PIN
TX10028012OtherAMERIGROUP PIN
TX6253640OtherCIGNA PIN
TX88645XOtherBCBSTX IND PIN
TX112541OtherSUPERIOR PIN
TX122904100OtherFIRSTCARE PIN
TX119121502Medicaid
TX137345810Medicaid
TX140442852Medicaid
TX7667110OtherAETNA PIN
TX6253640OtherCIGNA PIN
TX112541OtherSUPERIOR PIN
TX00U87ZOtherBCBSTX GRP PIN