Provider Demographics
NPI:1922746163
Name:TESHOME, LIDYA (DO)
Entity Type:Individual
Prefix:
First Name:LIDYA
Middle Name:
Last Name:TESHOME
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 NORTH IH-35
Mailing Address - Street 2:SUITE 310 CEC
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 NORTH IH-35
Practice Address - Street 2:SUITE 310 CEC
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701
Practice Address - Country:US
Practice Address - Phone:512-324-7890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-26
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP100788322084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology