Provider Demographics
NPI:1518385046
Name:PUNG, LYDA D (DO)
Entity Type:Individual
Prefix:MRS
First Name:LYDA
Middle Name:D
Last Name:PUNG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:12639 OLD TESSON RD
Mailing Address - Street 2:STE 100
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128
Mailing Address - Country:US
Mailing Address - Phone:816-478-0220
Mailing Address - Fax:816-795-3456
Practice Address - Street 1:19550 E. 39TH ST
Practice Address - Street 2:STE 300
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057
Practice Address - Country:US
Practice Address - Phone:816-478-0220
Practice Address - Fax:816-795-3456
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-01
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2016030785207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program