Provider Demographics
NPI:1255331922
Name:CALCAMUGGIO, LYLE T (MD)
Entity Type:Individual
Prefix:
First Name:LYLE
Middle Name:T
Last Name:CALCAMUGGIO
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 1:11311 BRIDGEPORT WAY SW
Mailing Address - Street 2:STE 302
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-3071
Mailing Address - Country:US
Mailing Address - Phone:253-985-2920
Mailing Address - Fax:253-985-6812
Practice Address - Street 1:11311 BRIDGEPORT WAY SW
Practice Address - Street 2:STE 302
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-3071
Practice Address - Country:US
Practice Address - Phone:253-985-2920
Practice Address - Fax:253-985-6812
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35060887207V00000X
WAMD60209694207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH01981OtherPARAMOUNT
OH160060036OtherRRMC
OH000000244956OtherANTHEM
OH13-50420OtherUHC
WA0301634OtherSTATE L&I
OH4557213OtherAETNA
OH0933986Medicaid
WAG8926726Medicare PIN
OH13-50420OtherUHC
CA0743744Medicare PIN