Healthcare Provider Details

I. General information

NPI: 1316127467
Provider Name (Legal Business Name): LISAMAR MALDONADO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2007
Last Update Date: 08/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 UNIVERSITY BLVD
GALVESTON TX
77555-5302
US

IV. Provider business mailing address

301 UNIVERSITY BLVD
GALVESTON TX
77555-5302
US

V. Phone/Fax

Practice location:
  • Phone: 409-772-2222
  • Fax:
Mailing address:
  • Phone: 409-772-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberN5830
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberN5830
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: