Provider Demographics
NPI:1215947635
Name:LISARA DIAGNOSTICS
Entity type:Organization
Organization Name:LISARA DIAGNOSTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:QUINTANILLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-614-3003
Mailing Address - Street 1:4319 MEDICAL DR # 131-113
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3381
Mailing Address - Country:US
Mailing Address - Phone:210-614-3003
Mailing Address - Fax:210-692-7898
Practice Address - Street 1:7220 LOUIS PASTEUR DR STE 160
Practice Address - Street 2:STE 160
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4535
Practice Address - Country:US
Practice Address - Phone:210-614-3003
Practice Address - Fax:210-692-7898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2885174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3553429OtherAETNA ID NUMBER
TXFTA076Medicare ID - Type UnspecifiedDR. L. FIALA