Provider Demographics
NPI:1588694459
Name:LYDA, MARK HARRY (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:HARRY
Last Name:LYDA
Suffix:
Gender:M
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:PO BOX 3405
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99220-3405
Mailing Address - Country:US
Mailing Address - Phone:509-892-2700
Mailing Address - Fax:509-892-2740
Practice Address - Street 1:13103 E MANSFIELD AVENUE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1642
Practice Address - Country:US
Practice Address - Phone:509-892-2700
Practice Address - Fax:509-892-2740
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN31836207ZP0102X
WAMD60797389207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3135931Medicaid
TN000000013333Medicaid
AR139243001Medicaid
AR98771OtherBLUE CROSS
WA2098536Medicaid
MS0121289Medicaid
TN3135931OtherBLUE CROSS BLUE SHIELD
TN3843923Medicaid
AR98771OtherBLUE CROSS
TN3135931Medicaid