Basic Information
| Provider Information | |||||||||
| NPI: | 1619910221 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHADRICK | ||||||||
| FirstName: | LIDIA | ||||||||
| MiddleName: | ALONSO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ALONSO | ||||||||
| OtherFirstName: | LIDIA | ||||||||
| OtherMiddleName: | CRISTINA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1172 NORTH MACLAY AVE. | ||||||||
| Address2: | |||||||||
| City: | SAN FERNANDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188981388 | ||||||||
| FaxNumber: | 8183654031 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 SAN FERNANDO RD. | ||||||||
| Address2: | |||||||||
| City: | SAN FERNANDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183658086 | ||||||||
| FaxNumber: | 8188984826 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | A91167 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.