Provider Demographics
NPI:1487827846
Name:BASHAM, LYLE DOUGLAS JR (LMT)
Entity Type:Individual
Prefix:
First Name:LYLE
Middle Name:DOUGLAS
Last Name:BASHAM
Suffix:JR
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12284 COUNTRY WHITE CIR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33635-6279
Mailing Address - Country:US
Mailing Address - Phone:813-395-3175
Mailing Address - Fax:
Practice Address - Street 1:12284 COUNTRY WHITE CIR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33635-6279
Practice Address - Country:US
Practice Address - Phone:813-395-3175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA52948174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist