Healthcare Provider Details

I. General information

NPI: 1891903415
Provider Name (Legal Business Name): TAMARA L LYDAY DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 07/21/2022
Certification Date: 05/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 PARK RIDGE LN
NORTH FOND DU LAC WI
54937-1385
US

IV. Provider business mailing address

3301 W FOREST HOME AVE
MILWAUKEE WI
53215-2843
US

V. Phone/Fax

Practice location:
  • Phone: 920-926-7800
  • Fax: 920-496-4705
Mailing address:
  • Phone: 414-389-2233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036121487
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11013444A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number48503
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: