Provider Demographics
NPI:1255324307
Name:CHANTILAS, LYDIA (MD)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:CHANTILAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11490 SPRINGFIELD PIKE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45246-3524
Mailing Address - Country:US
Mailing Address - Phone:513-672-3309
Mailing Address - Fax:513-672-3323
Practice Address - Street 1:85 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:FORT THOMAS
Practice Address - State:KY
Practice Address - Zip Code:41075-1793
Practice Address - Country:US
Practice Address - Phone:513-672-3309
Practice Address - Fax:513-672-3323
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY32380207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64323801Medicaid
KY64323801Medicaid