Provider Demographics
NPI:1841388253
Name:LYON, CHARLES R (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:R
Last Name:LYON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:309 ECORSE RD
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-5733
Mailing Address - Country:US
Mailing Address - Phone:734-484-0580
Mailing Address - Fax:734-484-6410
Practice Address - Street 1:309 ECORSE RD
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48198-5733
Practice Address - Country:US
Practice Address - Phone:734-484-0580
Practice Address - Fax:734-484-6410
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101005487207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE31614Medicare UPIN