Provider Demographics
NPI:1871508374
Name:FUSETTI, LYDIA ANN (MD)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:ANN
Last Name:FUSETTI
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1835 NW KINGS BLVD
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330
Mailing Address - Country:US
Mailing Address - Phone:541-753-3542
Mailing Address - Fax:541-752-0952
Practice Address - Street 1:1835 NW KINGS BLVD
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330
Practice Address - Country:US
Practice Address - Phone:541-753-3542
Practice Address - Fax:541-752-0952
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD12443208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR268359Medicaid
F18054Medicare UPIN