Provider Demographics
NPI:1356367106
Name:GUIDRY PRUETT, LISA ANN (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:GUIDRY PRUETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:GUIDRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:8201 PRESTON RD STE 440
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75225-6209
Mailing Address - Country:US
Mailing Address - Phone:214-675-3227
Mailing Address - Fax:972-435-4481
Practice Address - Street 1:8201 PRESTON RD STE 440
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75225-6209
Practice Address - Country:US
Practice Address - Phone:214-675-3227
Practice Address - Fax:972-435-4481
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD026450207N00000X
LA026450207N00000X
TXN3700207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1065331Medicaid
MS04158761Medicaid
LA06533Medicaid
LA4K621Medicare PIN
TX8L19549Medicare PIN