Provider Demographics
NPI:1417913302
Name:LYDIATT, DANIEL D (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:D
Last Name:LYDIATT
Suffix:
Gender:M
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:PO BOX 10190
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23450-0190
Mailing Address - Country:US
Mailing Address - Phone:800-477-5240
Mailing Address - Fax:757-463-6572
Practice Address - Street 1:8303 DODGE ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-4108
Practice Address - Country:US
Practice Address - Phone:402-354-5048
Practice Address - Fax:402-354-2585
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE163952085R0001X, 208600000X, 1223S0112X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1417913302Medicaid
NE10025044400Medicaid
NEE62322Medicare UPIN
NE277208Medicare PIN
NE10025044400Medicaid