Provider Demographics
NPI:1689789562
Name:CHARLES E LYON, MD, APMC
Entity Type:Organization
Organization Name:CHARLES E LYON, MD, APMC
Other - Org Name:VITREO-RETINAL ASSOCIATES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:LYON
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:318-222-8421
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:318-673-8970
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:318-673-8970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Not Answered207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
50356Medicare ID - Type Unspecified