MEDICARE: DR. LISA DIANE FAIRWEATHER D.O.

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	2084P0800X	Psychiatry Physician	L6256	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

General Provider Information

NPI Number	:	1720031404
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA DIANE FAIRWEATHER D.O.

Provider Business Mailing Address
First Line	:	5601 BRIDGE ST.
Second Line	:	#324
City	:	FT. WORTH
State	:	TX
Zip	:	76112
Country	:	US
Telephone Number	:	817-457-4646
Fax Number	:	817-492-7135

Provider Business Practice Location Address
First Line	:	5601 BRIDGE ST.
Second Line	:	#324
City	:	FT. WORTH
State	:	TX
Zip	:	76112
Country	:	US
Telephone Number	:	817-457-4646
Fax Number	:	817-492-7135

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

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	10/14/2010

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