Provider Demographics
NPI:1215006408
Name:LYLES, TONYA A (MD)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:A
Last Name:LYLES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY
Mailing Address - State:AL
Mailing Address - Zip Code:36854-3549
Mailing Address - Country:US
Mailing Address - Phone:334-756-5137
Mailing Address - Fax:334-756-6523
Practice Address - Street 1:4900 20TH AVE
Practice Address - Street 2:
Practice Address - City:VALLEY
Practice Address - State:AL
Practice Address - Zip Code:36854-3549
Practice Address - Country:US
Practice Address - Phone:334-756-5137
Practice Address - Fax:334-756-6523
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL23074208000000X
GA049732208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009922370Medicaid
H21764Medicare UPIN
AL009922370Medicaid