Provider Demographics
NPI:1417035775
Name:LYE, BENJAMIN (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:
Last Name:LYE
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:PO BOX 19189
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32245-9189
Mailing Address - Country:US
Mailing Address - Phone:904-743-1883
Mailing Address - Fax:904-743-5109
Practice Address - Street 1:3333 W 20TH ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32254-1703
Practice Address - Country:US
Practice Address - Phone:904-695-9145
Practice Address - Fax:904-695-2465
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME362712084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL15600OtherBLUECROSSBLUESHIELDFL
FL065385300Medicaid
FL320538OtherUNITEDBEHAVIORALHEALTH
FL15600OtherBLUECROSSBLUESHIELDFL
FL15600YMedicare ID - Type Unspecified