1063494003 NPI number — ERNESTO LIRA MD

Table of content: ERNESTO LIRA MD (NPI 1063494003)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063494003 NPI number — ERNESTO LIRA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIRA
Provider First Name:
ERNESTO
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063494003
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4833 SARATOGA PMB 606
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORPUS CHRISTI
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
361-851-0000
Provider Business Mailing Address Fax Number:
361-653-2538

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4613 S STAPLES ST STE C&D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORPUS CHRISTI
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78411-2605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
361-851-0000
Provider Business Practice Location Address Fax Number:
361-653-2543
Provider Enumeration Date:
11/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  K9599 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 165159801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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