Provider Demographics
NPI:1578655098
Name:LETTSOME, LYDELL CECIL (MD)
Entity type:Individual
Prefix:
First Name:LYDELL
Middle Name:CECIL
Last Name:LETTSOME
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 S STATE ST # MC3055
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901-3530
Mailing Address - Country:US
Mailing Address - Phone:302-480-1688
Mailing Address - Fax:302-480-9807
Practice Address - Street 1:640 S STATE ST FL 2
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-3530
Practice Address - Country:US
Practice Address - Phone:302-744-7500
Practice Address - Fax:302-735-3218
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0024789208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02461076Medicaid
NY1289H1Medicare ID - Type Unspecified
NYA400073791Medicare PIN
NY02461076Medicaid