Provider Demographics
NPI:1861563413
Name:POOMMIPANIT-BAJON, LIDA BEE (MD)
Entity type:Individual
Prefix:MS
First Name:LIDA
Middle Name:BEE
Last Name:POOMMIPANIT-BAJON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LIDA
Other - Middle Name:
Other - Last Name:BAJON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2055 N. PERRIS BLVD.
Mailing Address - Street 2:E6
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92571
Mailing Address - Country:US
Mailing Address - Phone:951-940-4176
Mailing Address - Fax:
Practice Address - Street 1:2055 N PERRIS BLVD
Practice Address - Street 2:E6
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571
Practice Address - Country:US
Practice Address - Phone:951-940-4176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70122207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI00D0248049OtherHMSA BILLING NUMBER
HI55674807Medicaid
HI55674807Medicaid
HI00D0248049OtherHMSA BILLING NUMBER