Provider Demographics
NPI:1861671281
Name:RIBEIRO, ANNELISE NATASHA (MD)
Entity Type:Individual
Prefix:
First Name:ANNELISE
Middle Name:NATASHA
Last Name:RIBEIRO
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 1:625 COUNTY ROAD 1503
Mailing Address - Street 2:
Mailing Address - City:ALBA
Mailing Address - State:TX
Mailing Address - Zip Code:75410-2638
Mailing Address - Country:US
Mailing Address - Phone:214-918-0037
Mailing Address - Fax:844-357-1903
Practice Address - Street 1:675 TOWN SQUARE BLVD BLDG 1A
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75040-2992
Practice Address - Country:US
Practice Address - Phone:903-474-1983
Practice Address - Fax:903-496-0534
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-01
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP6255208D00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX325375903Medicaid
TXP6255OtherTEXAS MEDICAL BOARD
TX325375904Medicaid