Provider Demographics
NPI:1790471910
Name:LYDE, DEREK ANDRE I
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:ANDRE
Last Name:LYDE
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 N EUTAW ST STE 201
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-6301
Mailing Address - Country:US
Mailing Address - Phone:410-225-9185
Mailing Address - Fax:410-225-7964
Practice Address - Street 1:821 N EUTAW ST STE 201
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-6301
Practice Address - Country:US
Practice Address - Phone:410-225-9185
Practice Address - Fax:410-225-7964
Is Sole Proprietor?:No
Enumeration Date:2023-04-12
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer