Provider Demographics
NPI:1770523391
Name:LYONS, KENNETH P (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:P
Last Name:LYONS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:20162 SW BIRCH ST
Mailing Address - Street 2:SUITE 150
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-0787
Mailing Address - Country:US
Mailing Address - Phone:949-221-1700
Mailing Address - Fax:949-221-1704
Practice Address - Street 1:20162 SW BIRCH ST
Practice Address - Street 2:SUITE 150
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-0787
Practice Address - Country:US
Practice Address - Phone:949-221-1700
Practice Address - Fax:949-221-1704
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG12843207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G128430OtherBLUE SHIELD
CA00G128430Medicaid
CA00G128430Medicaid