Provider Demographics
NPI:1609308162
Name:RUSSELL-ROY, LYDIA (MD)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:RUSSELL-ROY
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 1:887 CONGRESS ST STE 200
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3166
Mailing Address - Country:US
Mailing Address - Phone:207-771-5549
Mailing Address - Fax:
Practice Address - Street 1:887 CONGRESS ST STE 200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3166
Practice Address - Country:US
Practice Address - Phone:207-771-5549
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-03
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MEMD27683207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program