Provider Demographics
NPI:1538192646
Name:DE YBARRONDO, LISA EDMISTON (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:EDMISTON
Last Name:DE YBARRONDO
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 1:5656 KELLEY STREET
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77026-1967
Mailing Address - Country:US
Mailing Address - Phone:713-566-4541
Mailing Address - Fax:713-566-5844
Practice Address - Street 1:5656 KELLEY STREET
Practice Address - Street 2:500
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77026-1967
Practice Address - Country:US
Practice Address - Phone:713-566-4541
Practice Address - Fax:713-566-5844
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3696208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX125859206Medicaid
TX125859208Medicaid
TXTPI#125859206Medicaid
TX8G9223OtherBCBS
TX125859205Medicaid
TX125859208Medicaid
TXTXB140091Medicare PIN
TX8G9209Medicare PIN
TX125859205Medicaid
TX370012972Medicare PIN