Provider Demographics
NPI:1508833427
Name:KEFALIDOU, LYDIA (MD)
Entity Type:Individual
Prefix:DR
First Name:LYDIA
Middle Name:
Last Name:KEFALIDOU
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 1:264 PALM COAST PKWY NE
Mailing Address - Street 2:STE A
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-8217
Mailing Address - Country:US
Mailing Address - Phone:386-446-5505
Mailing Address - Fax:386-446-5077
Practice Address - Street 1:264 PALM COAST PKWY NE
Practice Address - Street 2:STE A
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-8217
Practice Address - Country:US
Practice Address - Phone:386-446-5505
Practice Address - Fax:386-446-5077
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME93402207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU5837XMedicare ID - Type Unspecified
I41466Medicare UPIN