Healthcare Provider Details

I. General information

NPI: 1295350809
Provider Name (Legal Business Name): LYDIA MARIAH DOUGLAS CPM, LDM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LYDIA MARIAH MARTINEZ

II. Dates (important events)

Enumeration Date: 06/09/2020
Last Update Date: 06/09/2020
Certification Date: 06/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1453 REDWOOD CIR
GRANTS PASS OR
97527-5523
US

IV. Provider business mailing address

1453 REDWOOD CIR
GRANTS PASS OR
97527-5523
US

V. Phone/Fax

Practice location:
  • Phone: 541-916-8333
  • Fax:
Mailing address:
  • Phone: 541-916-8333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberDEM-LD-10208453
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier20060005
Identifier TypeOTHER
Identifier State
Identifier IssuerNORTH AMERICAN REGISTRY OF MIDWIVES
# 2
IdentifierDEM-LD-10208453
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerOREGON STATE MIDWIFERY LICENSE NUMBER

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: