Provider Demographics
NPI:1053512491
Name:LYON, MILENA J (MD)
Entity Type:Individual
Prefix:
First Name:MILENA
Middle Name:J
Last Name:LYON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 S. WOOD STREET ROOM 380
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612
Mailing Address - Country:US
Mailing Address - Phone:312-996-6966
Mailing Address - Fax:
Practice Address - Street 1:1801 W TAYLOR ST
Practice Address - Street 2:SUITE 3E
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4319
Practice Address - Country:US
Practice Address - Phone:312-996-8666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036097128207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL104357509Medicaid