Provider Demographics
NPI:1235139460
Name:LYONS, CHARLES ROGER JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:ROGER
Last Name:LYONS
Suffix:JR
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 1:1025 MANCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-1425
Mailing Address - Country:US
Mailing Address - Phone:260-563-7421
Mailing Address - Fax:260-563-7725
Practice Address - Street 1:1025 MANCHESTER AVE
Practice Address - Street 2:
Practice Address - City:WABASH
Practice Address - State:IN
Practice Address - Zip Code:46992-1425
Practice Address - Country:US
Practice Address - Phone:260-563-7421
Practice Address - Fax:260-563-7725
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01022249207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000082846OtherBCBS
IN100084290AMedicaid
10336OtherPHP
D70862Medicare UPIN
IND80025449Medicare Oscar/Certification
IN861230Medicare PIN