Provider Demographics
NPI:1184673113
Name:LYON, EDD GILBERT (MD)
Entity Type:Individual
Prefix:
First Name:EDD
Middle Name:GILBERT
Last Name:LYON
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 1:1068 VAIL RD
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-9599
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1068 VAIL RD
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-9599
Practice Address - Country:US
Practice Address - Phone:802-447-0051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT42-6255207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0002387Medicaid
VTVT2387Medicare ID - Type Unspecified
VT0002387Medicaid