Provider Demographics
NPI:1851613079
Name:GHADERI, LIDA (MD)
Entity Type:Individual
Prefix:DR
First Name:LIDA
Middle Name:
Last Name:GHADERI
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 1:2222 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2304
Mailing Address - Country:US
Mailing Address - Phone:310-998-8600
Mailing Address - Fax:
Practice Address - Street 1:2222 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2304
Practice Address - Country:US
Practice Address - Phone:310-998-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-16
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA063230207R00000X, 207RA0000X, 207RG0300X, 207SG0201X, 2083P0901X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist