Provider Demographics
NPI:1205018207
Name:LYLE E WADSWORTH MD PA
Entity Type:Organization
Organization Name:LYLE E WADSWORTH MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LYLE
Authorized Official - Middle Name:E
Authorized Official - Last Name:WADSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-740-0224
Mailing Address - Street 1:890 N BOUNDARY AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-3173
Mailing Address - Country:US
Mailing Address - Phone:386-740-0224
Mailing Address - Fax:
Practice Address - Street 1:890 N BOUNDARY AVE STE 102
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-3173
Practice Address - Country:US
Practice Address - Phone:386-740-0224
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME30902207R00000X, 207RG0300X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL64391OtherBLUE CROSS BLUE SHIELD
FL000050266105OtherUNITEDHEALTHCARE
FL5490138OtherAETNA
FL2198298007OtherCIGNA
FL64391OtherBLUE CROSS BLUE SHIELD
FLD56770Medicare UPIN