Healthcare Provider Details

I. General information

NPI: 1538129481
Provider Name (Legal Business Name): LISA CORNELIUS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 10/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 W 49TH ST
AUSTIN TX
78756-3101
US

IV. Provider business mailing address

1100 W 49TH ST
AUSTIN TX
78756-3101
US

V. Phone/Fax

Practice location:
  • Phone: 512-776-6309
  • Fax:
Mailing address:
  • Phone: 512-776-6309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberL6844
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: