Healthcare Provider Details

I. General information

NPI: 1134145675
Provider Name (Legal Business Name): LISA A. DUCHAMP M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 01/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 W ROSEDALE ST
FORT WORTH TX
76104-7403
US

IV. Provider business mailing address

PO BOX 99371
FORT WORTH TX
76199-0371
US

V. Phone/Fax

Practice location:
  • Phone: 682-885-6726
  • Fax: 682-885-6729
Mailing address:
  • Phone: 682-885-1855
  • Fax: 682-885-7347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberK0288
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberK0288
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: