Provider Demographics
NPI:1801874532
Name:LYDON, PETER J (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:J
Last Name:LYDON
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 MASSACHUSETTS AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2690
Mailing Address - Country:US
Mailing Address - Phone:617-414-4505
Mailing Address - Fax:
Practice Address - Street 1:909 SUMNER ST
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:MA
Practice Address - Zip Code:02072-3396
Practice Address - Country:US
Practice Address - Phone:508-427-2480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA52243208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6178936Medicaid
MA8081330OtherAETNA US HEALTHCARE
MAM19130OtherBLUE CROSS & BLUE SHIELD
MA705041OtherTUFTS HEALTH PLAN
MA1702006OtherUNITEDHEALTHCARE
MA8613PCLOtherHARVARD PILGRIM HEALTH
MAA57020Medicare UPIN
MA6178936Medicaid