Provider Demographics
NPI:1629576210
Name:KRUSE PERALTA, LIDIA PAOLA (MD)
Entity Type:Individual
Prefix:
First Name:LIDIA
Middle Name:PAOLA
Last Name:KRUSE PERALTA
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 1:7760 WESTSIDE DR APT 103
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-1203
Mailing Address - Country:US
Mailing Address - Phone:314-835-7299
Mailing Address - Fax:
Practice Address - Street 1:200 MERCY CIR
Practice Address - Street 2:
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055
Practice Address - Country:US
Practice Address - Phone:760-725-1213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-29
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101267772207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program