Provider Demographics
NPI:1043300825
Name:WEISSER, LYDIA ELLIS (DO)
Entity Type:Individual
Prefix:MRS
First Name:LYDIA
Middle Name:ELLIS
Last Name:WEISSER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4128
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39304-4128
Mailing Address - Country:US
Mailing Address - Phone:601-581-7592
Mailing Address - Fax:601-483-5543
Practice Address - Street 1:1818 COLLEGE DRIVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39307-5429
Practice Address - Country:US
Practice Address - Phone:601-581-7592
Practice Address - Fax:601-483-5543
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS19817283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital