Healthcare Provider Details

I. General information

NPI: 1417913302
Provider Name (Legal Business Name): DANIEL D LYDIATT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 12/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8303 DODGE ST
OMAHA NE
68114-4108
US

IV. Provider business mailing address

PO BOX 10190
VIRGINIA BEACH VA
23450-0190
US

V. Phone/Fax

Practice location:
  • Phone: 402-354-5048
  • Fax: 402-354-2585
Mailing address:
  • Phone: 800-477-5240
  • Fax: 757-463-6572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number16395
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number16395
License Number StateNE
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number16395
License Number StateNE
# 4
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number16395
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: