Provider Demographics
NPI:1194017418
Name:STEPHENSON, LYLE ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:LYLE
Middle Name:ROBERT
Last Name:STEPHENSON
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 1:600 CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70663-5052
Mailing Address - Country:US
Mailing Address - Phone:337-527-6371
Mailing Address - Fax:
Practice Address - Street 1:600 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70663-5052
Practice Address - Country:US
Practice Address - Phone:337-527-6371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-04
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LAMD.205465208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program