Provider Demographics
NPI:1558380303
Name:LYON, CHARLES ELIOT (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:ELIOT
Last Name:LYON
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 1:836 OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-2102
Mailing Address - Country:US
Mailing Address - Phone:318-222-8421
Mailing Address - Fax:318-222-0651
Practice Address - Street 1:836 OLIVE ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-2102
Practice Address - Country:US
Practice Address - Phone:318-222-8421
Practice Address - Fax:318-222-0651
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA016354207WX0107X
TXM2383207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1352543Medicaid
LA50356F600Medicare ID - Type Unspecified
LA1352543Medicaid