Provider Demographics
NPI:1053405712
Name:LIDESTRI, PAULA A (MD)
Entity type:Individual
Prefix:
First Name:PAULA
Middle Name:A
Last Name:LIDESTRI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16219 DEER RUN ROAD
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1150 N INDIAN CANYON DR
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262
Practice Address - Country:US
Practice Address - Phone:760-323-6511
Practice Address - Fax:760-323-6538
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35086210208100000X
NY225974208100000X
CAA110395208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2572603Medicaid
OH2572603Medicaid