Provider Demographics
NPI:1295758803
Name:EVANS, LYDIA M (MD)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:M
Last Name:EVANS
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 1:229 KING ST
Mailing Address - Street 2:
Mailing Address - City:CHAPPAQUA
Mailing Address - State:NY
Mailing Address - Zip Code:10514-3461
Mailing Address - Country:US
Mailing Address - Phone:914-238-1500
Mailing Address - Fax:914-238-8191
Practice Address - Street 1:229 KING ST
Practice Address - Street 2:
Practice Address - City:CHAPPAQUA
Practice Address - State:NY
Practice Address - Zip Code:10514-3461
Practice Address - Country:US
Practice Address - Phone:914-238-1500
Practice Address - Fax:914-238-8191
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY153287207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5C6087OtherHEALTHNET
NY0486480OtherAETNA/U.S.HEALTHCARE
NYWP518OtherOXFORD
NY39H78OtherBLUE SHIELD
NY39H781Medicare PIN
NY0486480OtherAETNA/U.S.HEALTHCARE