Provider Demographics
NPI:1417165903
Name:LYALL, JOHN GREGORY (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:GREGORY
Last Name:LYALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-718-0100
Mailing Address - Fax:336-718-0120
Practice Address - Street 1:1381 WESTGATE CENTER DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2934
Practice Address - Country:US
Practice Address - Phone:336-718-0100
Practice Address - Fax:336-718-0120
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007-00989207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1417165903Medicaid
NC45516EMedicare UPIN
NCNCD360AMedicare PIN
NCNCD360C904Medicare PIN