Provider Demographics
NPI:1659328870
Name:CAROLYN B LYDE MD PA
Entity Type:Organization
Organization Name:CAROLYN B LYDE MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:B
Authorized Official - Last Name:LYDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-436-0358
Mailing Address - Street 1:324 W MAIN STREET
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75057-3641
Mailing Address - Country:US
Mailing Address - Phone:972-436-0358
Mailing Address - Fax:972-353-3750
Practice Address - Street 1:324 W MAIN STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75057-3641
Practice Address - Country:US
Practice Address - Phone:972-436-0358
Practice Address - Fax:972-353-3750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0585207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00870RMedicare PIN