Provider Demographics
NPI:1295714590
Name:LYSTER, MICHAEL J IV (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:LYSTER
Suffix:IV
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:703 TYLER ST
Mailing Address - Street 2:SUITE 250
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-3367
Mailing Address - Country:US
Mailing Address - Phone:440-414-9300
Mailing Address - Fax:216-201-5588
Practice Address - Street 1:703 TYLER ST
Practice Address - Street 2:SUITE 250
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-3367
Practice Address - Country:US
Practice Address - Phone:440-414-9300
Practice Address - Fax:216-201-5588
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2021-01-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OH34005911207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH341221800115OtherCARESOURCE
060063317OtherRAILROAD MEDICARE
OH85116OtherKAISER
OH000000193314OtherANTHEM
OH0974012Medicare ID - Type Unspecified
OH85116OtherKAISER
OH341221800115OtherCARESOURCE