Provider Demographics
NPI:1336208305
Name:LYON, JOHN BENTON (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:BENTON
Last Name:LYON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1965
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-1965
Mailing Address - Country:US
Mailing Address - Phone:601-649-2450
Mailing Address - Fax:601-649-0556
Practice Address - Street 1:1431 W 10TH ST
Practice Address - Street 2:SUITE 2
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-2626
Practice Address - Country:US
Practice Address - Phone:601-649-2450
Practice Address - Fax:601-649-0556
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17566174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS000125873Medicaid
MSG35320Medicare UPIN
MS00125873Medicaid