Provider Demographics
NPI:1518939354
Name:BANUELOS, LYDIA (MD)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:BANUELOS
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 1:888 S. DISNEYLAND DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92802-1828
Mailing Address - Country:US
Mailing Address - Phone:714-901-2007
Mailing Address - Fax:714-901-2003
Practice Address - Street 1:947 S. ANAHEIM BLVD.
Practice Address - Street 2:SUITE 120
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-5590
Practice Address - Country:US
Practice Address - Phone:714-821-4666
Practice Address - Fax:714-533-6800
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33339207W00000X
CAA65937207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP00447251OtherRAILROAD MEDICARE
AZ887440Medicaid
AZZ84942Medicare PIN
AZ887440Medicaid
AZP00447251OtherRAILROAD MEDICARE