Provider Demographics
NPI:1639180375
Name:LYDON, EDWARD JOSEPH (CO)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:JOSEPH
Last Name:LYDON
Suffix:
Gender:M
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 FIRST STREET
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-4746
Mailing Address - Country:US
Mailing Address - Phone:707-428-3800
Mailing Address - Fax:707-428-1444
Practice Address - Street 1:712 FIRST STREET
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-4746
Practice Address - Country:US
Practice Address - Phone:707-428-3800
Practice Address - Fax:707-428-1444
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1167222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXA0011670Medicaid
CAZZZ85255ZOtherBLUE SHIELD/BLUE CROSS
CAXA0011670Medicaid