Provider Demographics
NPI:1124000294
Name:LIDSTONE JAYANATH, ELIZABETH M (MD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:M
Last Name:LIDSTONE JAYANATH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:326 NICHOLS ROAD
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420-1914
Mailing Address - Country:US
Mailing Address - Phone:978-878-8100
Mailing Address - Fax:978-878-8418
Practice Address - Street 1:175 CONNORS STREET
Practice Address - Street 2:
Practice Address - City:GARDER
Practice Address - State:MA
Practice Address - Zip Code:01440
Practice Address - Country:US
Practice Address - Phone:978-410-6100
Practice Address - Fax:978-410-6109
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA156974208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
J19766OtherBLUE SHIELD HMO BLUE
J19766OtherBLUE CARE ELECT
J19766OtherBLUE SHIELD INDEMNITY
1836498OtherFIRST HEALTH
7521481OtherCIGNA HEALTH PLAN
3188787OtherMEDICAID/WELFARE
MA3188787Medicaid
33367OtherCHILDRENS MED SECURITY PL
33367OtherHEALTHY START
42389OtherFALLON COMMUNITY HLTH PL
AA1277OtherHARVARD PILGRIM HEALTHCAR
042472266OtherPRIVATE HEALTHCARE SYSTEM
3188787OtherMEDICAID PCC
A29170OtherMEDICARE B
042472266OtherONE HEALTH PLAN
7575320OtherAETNA/US HEALTHCARE
784154OtherMVP HEALTH CARE
042472266OtherHEALTHCARE VALUE MNGMENT
7575320OtherAETNA/US HEALTHCARE
A29170Medicare ID - Type Unspecified