Provider Demographics
NPI:1811900558
Name:HERRERA-MATA, LYDIA
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:HERRERA-MATA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LYDIA
Other - Middle Name:
Other - Last Name:HERRERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2625 E DIVISADERO ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721-1431
Mailing Address - Country:US
Mailing Address - Phone:559-443-2682
Mailing Address - Fax:559-443-2681
Practice Address - Street 1:2823 FRESNO ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93721-1324
Practice Address - Country:US
Practice Address - Phone:559-499-6450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA75245207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H73903Medicare UPIN
BH7620746OtherDEA