Provider Demographics
NPI:1235620287
Name:PARK, LYDIA SOMI
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:SOMI
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10790 RANCHO BERNARDO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:858-824-5383
Mailing Address - Fax:858-964-3125
Practice Address - Street 1:10666 N TORREY PINES RD
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1027
Practice Address - Country:US
Practice Address - Phone:858-554-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-25
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA166501207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine