Provider Demographics
NPI:1043230204
Name:LYDON, PAUL MATTHEW (DC)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:MATTHEW
Last Name:LYDON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1186 CHURCH STREET
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:PA
Mailing Address - Zip Code:18444
Mailing Address - Country:US
Mailing Address - Phone:570-558-1855
Mailing Address - Fax:570-558-1856
Practice Address - Street 1:1186 CHURCH STREET
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:PA
Practice Address - Zip Code:18444
Practice Address - Country:US
Practice Address - Phone:570-842-5131
Practice Address - Fax:570-842-5126
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC008039L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1015959670001Medicaid
PA053163Medicare ID - Type Unspecified
U87971Medicare UPIN
PA1015959670001Medicaid