Basic Information
| Provider Information | |||||||||
| NPI: | 1417904525 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CASSORLA | ||||||||
| FirstName: | LYDIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1635 DIVISADERO STREET | ||||||||
| Address2: | SUITE 625, BOX 1821 | ||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941430001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154764029 | ||||||||
| FaxNumber: | 4154764150 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 PARNASSUS AVE | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941432204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154762131 | ||||||||
| FaxNumber: | 4154769516 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | G44698 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00G446980 | 05 | CA | MEDICAID |