Provider Demographics
NPI:1649675778
Name:DAVID H LYON A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:DAVID H LYON A PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-552-7551
Mailing Address - Street 1:PO BOX 579120
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95357-9120
Mailing Address - Country:US
Mailing Address - Phone:888-582-0814
Mailing Address - Fax:209-526-6841
Practice Address - Street 1:4701 SISK RD
Practice Address - Street 2:SUITE 103
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-9320
Practice Address - Country:US
Practice Address - Phone:888-582-0814
Practice Address - Fax:209-526-6841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-31
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00A431800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A431800OtherSTATE LICENSE NUMBER