Provider Demographics
NPI:1225564750
Name:SURYAKUMAR, LYDIA DHARSHINI (MD)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:DHARSHINI
Last Name:SURYAKUMAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SURYAKUMAR
Other - Middle Name:DHARSHINI
Other - Last Name:LYDIA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1040 FLYNN RD
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-5092
Mailing Address - Country:US
Mailing Address - Phone:805-673-3930
Mailing Address - Fax:805-659-3217
Practice Address - Street 1:1200 N VENTURA RD STE E
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-3827
Practice Address - Country:US
Practice Address - Phone:805-988-0053
Practice Address - Fax:805-988-0554
Is Sole Proprietor?:No
Enumeration Date:2017-05-03
Last Update Date:2020-06-16
Deactivation Date:2017-12-06
Deactivation Code:
Reactivation Date:2017-12-12
Provider Licenses
StateLicense IDTaxonomies
CAA166986207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine