Provider Demographics
NPI:1356347561
Name:WADSWORTH, LYLE E (MD)
Entity type:Individual
Prefix:DR
First Name:LYLE
Middle Name:E
Last Name:WADSWORTH
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 1:890 N BOUNDARY AVE
Mailing Address - Street 2:STE 102
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-3173
Mailing Address - Country:US
Mailing Address - Phone:386-740-0224
Mailing Address - Fax:386-740-9711
Practice Address - Street 1:890 N BOUNDARY AVE
Practice Address - Street 2:STE 102
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-3173
Practice Address - Country:US
Practice Address - Phone:386-740-0224
Practice Address - Fax:386-740-9711
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME30902207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000050266105OtherUNITEDHEALTHCARE
FL2198298007OtherCIGNA
FL64391OtherBC/BS
FL5490138OtherAETNA
FL000050266105OtherUNITEDHEALTHCARE
FL5490138OtherAETNA