Provider Demographics
NPI:1003838103
Name:EATEDALI, LIDA (MD)
Entity Type:Individual
Prefix:DR
First Name:LIDA
Middle Name:
Last Name:EATEDALI
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 1:306 INDIAN CREEK DR
Mailing Address - Street 2:WILKES WOOD
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-7826
Mailing Address - Country:US
Mailing Address - Phone:570-820-0465
Mailing Address - Fax:
Practice Address - Street 1:1111 EAST END BLVD
Practice Address - Street 2:VAMC.
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18711
Practice Address - Country:US
Practice Address - Phone:570-824-3521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301084937207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301084937OtherMD LICENSE