Provider Demographics
NPI:1659515617
Name:LYSSY, DOUGLAS (MD/MBA)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:
Last Name:LYSSY
Suffix:
Gender:M
Credentials:MD/MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5930 GULF OF MEXICO DR
Mailing Address - Street 2:
Mailing Address - City:LONGBOAT KEY
Mailing Address - State:FL
Mailing Address - Zip Code:34228-1704
Mailing Address - Country:US
Mailing Address - Phone:203-804-8894
Mailing Address - Fax:
Practice Address - Street 1:2020 59TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-4604
Practice Address - Country:US
Practice Address - Phone:941-792-6611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-21
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME110142207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine