Provider Demographics
NPI:1083679062
Name:LYSNE, DWIGHT H (MD, MDIV)
Entity Type:Individual
Prefix:DR
First Name:DWIGHT
Middle Name:H
Last Name:LYSNE
Suffix:
Gender:M
Credentials:MD, MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7212 OYSTER LN
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28411-7132
Mailing Address - Country:US
Mailing Address - Phone:910-465-1935
Mailing Address - Fax:910-399-3928
Practice Address - Street 1:20 S 16TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-4924
Practice Address - Country:US
Practice Address - Phone:877-456-6729
Practice Address - Fax:910-399-3928
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND55122084P0804X
MN282902084P0804X
NC2003013782084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN94D78LYOtherMNBC/BS
ND15992Medicaid
MN937078100Medicaid
ND19977OtherNDBCBS
260045000OtherRAILROAD MEDICARE
NC891378JMedicaid
ND15992Medicaid
ND19977Medicare ID - Type Unspecified