Provider Demographics
NPI:1154613735
Name:BERNUY, LIS CAROL (MD)
Entity type:Individual
Prefix:
First Name:LIS
Middle Name:CAROL
Last Name:BERNUY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LIS
Other - Middle Name:CAROL
Other - Last Name:CRUZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2800 S TEXAS AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-5361
Mailing Address - Country:US
Mailing Address - Phone:979-774-2060
Mailing Address - Fax:979-776-5914
Practice Address - Street 1:1612 W VILLA MARIA RD STE 130
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77807-2309
Practice Address - Country:US
Practice Address - Phone:979-690-4836
Practice Address - Fax:979-690-4837
Is Sole Proprietor?:No
Enumeration Date:2011-05-13
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ0413207Q00000X
CT64163207P00000X
MI4301098212207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX341070601Medicaid