Provider Demographics
NPI:1083178198
Name:LIDAYWA, VICTOR ERUDE (DPT)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:ERUDE
Last Name:LIDAYWA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 E SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-3223
Mailing Address - Country:US
Mailing Address - Phone:309-837-1748
Mailing Address - Fax:
Practice Address - Street 1:1701 W JACKSON ST
Practice Address - Street 2:STE C
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-3175
Practice Address - Country:US
Practice Address - Phone:309-331-3590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-23
Last Update Date:2019-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.017800225100000X, 261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist