Basic Information
| Provider Information | |||||||||
| NPI: | 1669796389 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KUO-BONDE | ||||||||
| FirstName: | LYDIA | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | KUO | ||||||||
| OtherFirstName: | LYDIA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1121 SITUS CT | ||||||||
| Address2: | STE 170 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276064279 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198342767 | ||||||||
| FaxNumber: | 9198340234 | ||||||||
| Practice Location | |||||||||
| Address1: | 1215 LEE ST FL 1 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229080816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4342430630 | ||||||||
| FaxNumber: | 4349821618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2010 | ||||||||
| LastUpdateDate: | 12/06/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2085P0229X | 0101260166 | VA | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0202X | 2017-02262 | NC | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | A118553 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1669796389 | 05 | VA | MEDICAID |