Provider Demographics
NPI:1245294966
Name:MINNICH, LISA ANN (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANN
Last Name:MINNICH
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:3001 GEORGE BUSH HWY
Mailing Address - Street 2:SUITE 250
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-3542
Mailing Address - Country:US
Mailing Address - Phone:214-343-6663
Mailing Address - Fax:214-343-2814
Practice Address - Street 1:3001 E PRESIDENT GEORGE BUSH HWY
Practice Address - Street 2:SUITE 250
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75082-3542
Practice Address - Country:US
Practice Address - Phone:214-343-6663
Practice Address - Fax:214-343-2814
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXK68912080N0001X
OH35-06-53342080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0104210Medicaid
TXG82109Medicare UPIN