Healthcare Provider Details

I. General information

NPI: 1194916874
Provider Name (Legal Business Name): LIZA DE OLAZO BANAAG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2007
Last Update Date: 06/19/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17218 PRESTON RD # 2000
DALLAS TX
75252-4018
US

IV. Provider business mailing address

PO BOX 742712
ATLANTA GA
30374-2712
US

V. Phone/Fax

Practice location:
  • Phone: 877-866-7123
  • Fax:
Mailing address:
  • Phone: 877-866-7123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License NumberK5793
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberK5793
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: