Provider Demographics
NPI:1760833644
Name:MAEHARA, LISA MARIKO (DO)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:MARIKO
Last Name:MAEHARA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3055 W SOUTHLAKE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6730
Mailing Address - Country:US
Mailing Address - Phone:682-593-7639
Mailing Address - Fax:682-593-0739
Practice Address - Street 1:3055 W SOUTHLAKE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6730
Practice Address - Country:US
Practice Address - Phone:682-593-7639
Practice Address - Fax:682-593-0739
Is Sole Proprietor?:No
Enumeration Date:2016-06-22
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT4420207Q00000X
MI5101022739207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine