Healthcare Provider Details

I. General information

NPI: 1518939354
Provider Name (Legal Business Name): LYDIA BANUELOS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 09/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

947 S. ANAHEIM BLVD. SUITE 120
ANAHEIM CA
92805-5590
US

IV. Provider business mailing address

888 S. DISNEYLAND DRIVE SUITE 100
ANAHEIM CA
92802-1828
US

V. Phone/Fax

Practice location:
  • Phone: 714-821-4666
  • Fax: 714-533-6800
Mailing address:
  • Phone: 714-901-2007
  • Fax: 714-901-2003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number33339
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberA65937
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: