Provider Demographics
NPI:1114916350
Name:LYSTER, MICHAEL T (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:LYSTER
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 1:101 CIVIC CENTER LN
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5607
Mailing Address - Country:US
Mailing Address - Phone:928-453-3761
Mailing Address - Fax:928-453-3771
Practice Address - Street 1:101 CIVIC CENTER LN
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5607
Practice Address - Country:US
Practice Address - Phone:928-453-3761
Practice Address - Fax:928-453-3771
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036081248207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036081248Medicaid
AZ505784Medicaid
ILL56904Medicare PIN
IL900001507Medicare PIN
ILL56365Medicare PIN
AZZ136915Medicare PIN
F49022Medicare UPIN
AZ505784Medicaid
ILL62124Medicare PIN