Provider Demographics
NPI:1184618555
Name:LYON, CHARLES MONROE (MD FACS)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:MONROE
Last Name:LYON
Suffix:
Gender:M
Credentials:MD FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 N OREGON ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-3351
Mailing Address - Country:US
Mailing Address - Phone:915-533-8118
Mailing Address - Fax:915-533-9669
Practice Address - Street 1:4311 E LOHMAN AVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8255
Practice Address - Country:US
Practice Address - Phone:505-556-6855
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD7623208600000X
NM98325208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMW6043Medicaid
C18637Medicare UPIN
TX00L115Medicare ID - Type Unspecified