Provider Demographics
NPI:1679747935
Name:AYOUB-RODRIGUEZ, LISA (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:AYOUB-RODRIGUEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 ALBERTA AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905-2709
Mailing Address - Country:US
Mailing Address - Phone:915-545-6720
Mailing Address - Fax:915-545-5755
Practice Address - Street 1:4801 ALBERTA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-2707
Practice Address - Country:US
Practice Address - Phone:915-545-6810
Practice Address - Fax:915-545-8859
Is Sole Proprietor?:No
Enumeration Date:2008-04-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01069736A208000000X
TX43986208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201023560Medicaid
IN000000717320OtherANTHEM PROVIDER NUMBER
IN000000717320OtherANTHEM PROVIDER NUMBER