Provider Demographics
NPI:1114903465
Name:LIDAGOSTER, LIDIA (MEDICAL DOCTOR)
Entity Type:Individual
Prefix:DR
First Name:LIDIA
Middle Name:
Last Name:LIDAGOSTER
Suffix:
Gender:F
Credentials:MEDICAL DOCTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 MEMORIAL HWY STE LL7
Mailing Address - Street 2:
Mailing Address - City:NEW ROCHELLE
Mailing Address - State:NY
Mailing Address - Zip Code:10801-5642
Mailing Address - Country:US
Mailing Address - Phone:212-707-8662
Mailing Address - Fax:212-582-0888
Practice Address - Street 1:175 MEMORIAL HWY STE LL7
Practice Address - Street 2:
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10801-5642
Practice Address - Country:US
Practice Address - Phone:212-707-8662
Practice Address - Fax:212-582-0888
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1986812084B0002X, 2084P0015X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084B0002XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyObesity Medicine
No2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01619630Medicaid
BL4391075OtherDEA
G03709Medicare UPIN
NY18750EH171Medicare PIN