Healthcare Provider Details

I. General information

NPI: 1851927867
Provider Name (Legal Business Name): LIDIA PARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2020
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 S FAIRMONT AVE
LODI CA
95240-5118
US

IV. Provider business mailing address

3819 ROSEPARKE WAY
SACRAMENTO CA
95834-2083
US

V. Phone/Fax

Practice location:
  • Phone: 209-334-3411
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number182789
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: