Healthcare Provider Details

I. General information

NPI: 1871118828
Provider Name (Legal Business Name): VICTORIA LYDIA EGEDUS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: VICTORIA LYDIA EGEDUS HERNANDEZ DO

II. Dates (important events)

Enumeration Date: 06/15/2020
Last Update Date: 06/15/2020
Certification Date: 06/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 E MICHIGAN AVE
LANSING MI
48912-1811
US

IV. Provider business mailing address

914 GRAND CT
LANSING MI
48906-5118
US

V. Phone/Fax

Practice location:
  • Phone: 517-432-9277
  • Fax: 517-432-9414
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number5151014159
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: