Provider Demographics
NPI:1184660664
Name:LYELL, REGGIE DUANE (MD)
Entity Type:Individual
Prefix:DR
First Name:REGGIE
Middle Name:DUANE
Last Name:LYELL
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:PO BOX 455
Mailing Address - Street 2:
Mailing Address - City:CORYDON
Mailing Address - State:IN
Mailing Address - Zip Code:47112-0455
Mailing Address - Country:US
Mailing Address - Phone:812-738-4155
Mailing Address - Fax:812-738-6104
Practice Address - Street 1:313 FEDERAL DR NW
Practice Address - Street 2:SUITE 200
Practice Address - City:CORYDON
Practice Address - State:IN
Practice Address - Zip Code:47112-3070
Practice Address - Country:US
Practice Address - Phone:812-738-4155
Practice Address - Fax:812-738-6104
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042535207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN12044V10062OtherAHDSH
IN351920057OtherGROUP TAX ID
IN080062749OtherMEDICARE RR
IN0180571OtherUNHEALTHCARE
IN100380200AMedicaid
IN1017630001OtherDMERC
IN338886POtherSIHO
IN42639OtherANTHEM
IN351920057OtherGROUP TAX ID
IN338886POtherSIHO