MEDICARE: DR. ELMER J. LIZAMA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	22747	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	680007553	OTHER	TX	RAIL ROAD
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	86075A	OTHER	TX	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1477583151
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELMER J. LIZAMA

Provider Business Mailing Address
First Line	:	10226 DEERMONT TRL
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75243-2525
Country	:	US
Telephone Number	:	972-644-6398
Fax Number	:

Provider Business Practice Location Address
First Line	:	8059 SCYENE CIR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75227-5534
Country	:	US
Telephone Number	:	800-257-8715
Fax Number	:	800-819-1655

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/05/2006
Last Update Date	:	07/09/2007

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