MEDICARE: LISA ODAIBO M.D.

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	208000000X	Pediatrics Physician	R7838	TX

General Provider Information

NPI Number	:	1912206368
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA ODAIBO M.D.

Provider Business Mailing Address
First Line	:	6211 SPENCERS GLEN WAY
Second Line	:
City	:	SUGAR LAND
State	:	TX
Zip	:	77479-5059
Country	:	US
Telephone Number	:	240-423-8721
Fax Number	:

Provider Business Practice Location Address
First Line	:	5598 NORTH FWY
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77076-4702
Country	:	US
Telephone Number	:	281-628-2030
Fax Number	:

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

Provider Enumeration Date	:	03/24/2011
Last Update Date	:	08/19/2022

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