Provider Demographics
NPI:1811008410
Name:BOURNE, LIZA P (MD)
Entity type:Individual
Prefix:
First Name:LIZA
Middle Name:P
Last Name:BOURNE
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 12740
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92685-2740
Mailing Address - Country:US
Mailing Address - Phone:562-809-3527
Mailing Address - Fax:
Practice Address - Street 1:3500 W WHEATLAND RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-3460
Practice Address - Country:US
Practice Address - Phone:214-947-7777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM9925207PE0004X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX196498302Medicaid
TX196498301Medicaid
TX8AN321OtherBCBSTX
TX196498302Medicaid
TX8AN321OtherBCBSTX