Provider Demographics
NPI:1376572115
Name:AGHDAM, LIDA (MD)
Entity Type:Individual
Prefix:
First Name:LIDA
Middle Name:
Last Name:AGHDAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4819 STATE HIGHWAY 121 STE 14
Mailing Address - Street 2:
Mailing Address - City:THE COLONY
Mailing Address - State:TX
Mailing Address - Zip Code:75056-2908
Mailing Address - Country:US
Mailing Address - Phone:817-488-7878
Mailing Address - Fax:817-488-7877
Practice Address - Street 1:4819 STATE HIGHWAY 121 STE 14
Practice Address - Street 2:
Practice Address - City:THE COLONY
Practice Address - State:TX
Practice Address - Zip Code:75056-2908
Practice Address - Country:US
Practice Address - Phone:817-488-7878
Practice Address - Fax:817-488-7877
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4208207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8BM85OtherBCBS OF TEXAS
TX8F9788Medicare PIN
TXH74638Medicare UPIN