Provider Demographics
NPI:1669580882
Name:LYMAN, JOHN C (OD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:LYMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 TWILL VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-6566
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2330 MID RIVERS MALL
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-4377
Practice Address - Country:US
Practice Address - Phone:636-970-2448
Practice Address - Fax:636-279-2483
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO3167152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOT97031Medicare UPIN