Healthcare Provider Details

I. General information

NPI: 1417273889
Provider Name (Legal Business Name): LISA MARIE RUIZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2010
Last Update Date: 08/06/2021
Certification Date: 08/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 N WALNUT ST STE 905
BLOOMINGTON IN
47404-2008
US

IV. Provider business mailing address

2620 N WALNUT ST STE 905
BLOOMINGTON IN
47404-2008
US

V. Phone/Fax

Practice location:
  • Phone: 812-508-6132
  • Fax:
Mailing address:
  • Phone: 812-269-6163
  • Fax: 765-202-7275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number01079413A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number01079413A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: