Provider Demographics
NPI:1710190889
Name:EDMUNDSON, LIDA LACY (MD)
Entity Type:Individual
Prefix:
First Name:LIDA
Middle Name:LACY
Last Name:EDMUNDSON
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 1:12700 HILLCREST RD
Mailing Address - Street 2:SUITE 260
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2033
Mailing Address - Country:US
Mailing Address - Phone:972-789-9319
Mailing Address - Fax:972-789-9324
Practice Address - Street 1:12700 HILLCREST RD
Practice Address - Street 2:SUITE 260
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2033
Practice Address - Country:US
Practice Address - Phone:972-789-9319
Practice Address - Fax:972-789-9324
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD32102084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD49579Medicare UPIN
TX00P843Medicare ID - Type Unspecified