Provider Demographics
NPI:1851342539
Name:CANAVAN, LYDIA (MD)
Entity type:Individual
Prefix:DR
First Name:LYDIA
Middle Name:
Last Name:CANAVAN
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:PO BOX 910229
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92191-0229
Mailing Address - Country:US
Mailing Address - Phone:858-564-1400
Mailing Address - Fax:858-564-1500
Practice Address - Street 1:10150 SORRENTO VALLEY RD
Practice Address - Street 2:SUITE 320
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1635
Practice Address - Country:US
Practice Address - Phone:858-454-4235
Practice Address - Fax:858-454-4644
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG581662085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G581660Medicaid
WG58166HMedicare ID - Type Unspecified
WG58166LMedicare ID - Type Unspecified
CA00G581660Medicaid
WG58166GMedicare ID - Type Unspecified
WG58166IMedicare ID - Type Unspecified