Healthcare Provider Details

I. General information

NPI: 1972594893
Provider Name (Legal Business Name): LYDIA CARPENTER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 08/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3025 GOVERNORS PLACE BLVD
DAYTON OH
45409-1330
US

IV. Provider business mailing address

3025 GOVERNORS PLACE BLVD
DAYTON OH
45409-1330
US

V. Phone/Fax

Practice location:
  • Phone: 937-293-5567
  • Fax: 937-293-5568
Mailing address:
  • Phone: 937-293-5567
  • Fax: 937-293-5568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number35.133591
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA84038
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: