Basic Information
| Provider Information | |||||||||
| NPI: | 1619989142 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NJAMFA | ||||||||
| FirstName: | LYDIA | ||||||||
| MiddleName: | OLUWATOYIN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 708 W SPRING VALLEY RD | ||||||||
| Address2: | SUITE 399 | ||||||||
| City: | RICHARDSON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750807216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2145709400 | ||||||||
| FaxNumber: | 9727927268 | ||||||||
| Practice Location | |||||||||
| Address1: | 708 W SPRING VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | RICHARDSON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750807216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2145709400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 02/13/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | L0884 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 10017340 | 01 | TX | AMERIGROUP | OTHER | 1703118-01 | 05 | TX | MEDICAID | 1703118-02 | 05 | TX | MEDICAID |