Healthcare Provider Details

I. General information

NPI: 1720031404
Provider Name (Legal Business Name): LISA DIANE FAIRWEATHER D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LISA DIANE ALLOJU D.O.

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 10/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 BRIDGE ST. #324
FT. WORTH TX
76112
US

IV. Provider business mailing address

5601 BRIDGE ST. #324
FT. WORTH TX
76112
US

V. Phone/Fax

Practice location:
  • Phone: 817-457-4646
  • Fax: 817-492-7135
Mailing address:
  • Phone: 817-457-4646
  • Fax: 817-492-7135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberL6256
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: