Healthcare Provider Details

I. General information

NPI: 1225564750
Provider Name (Legal Business Name): LYDIA DHARSHINI SURYAKUMAR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SURYAKUMAR DHARSHINI LYDIA

II. Dates (important events)

Enumeration Date: 05/03/2017
Last Update Date: 06/16/2020
Certification Date: 06/16/2020
Deactivation Date: 12/06/2017
Reactivation Date: 12/12/2017

III. Provider practice location address

1200 N VENTURA RD STE E
OXNARD CA
93030-3827
US

IV. Provider business mailing address

1040 FLYNN RD
CAMARILLO CA
93012-5092
US

V. Phone/Fax

Practice location:
  • Phone: 805-988-0053
  • Fax: 805-988-0554
Mailing address:
  • Phone: 805-673-3930
  • Fax: 805-659-3217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA166986
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: