Provider Demographics
NPI:1801871199
Name:LYLES, CRAIG R (MD)
Entity type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:R
Last Name:LYLES
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 1:425 BROAD ST SE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3751
Mailing Address - Country:US
Mailing Address - Phone:770-718-9776
Mailing Address - Fax:
Practice Address - Street 1:425 BROAD ST SE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3751
Practice Address - Country:US
Practice Address - Phone:770-718-9776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-09
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL000259812085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA553281085BMedicaid
AL009980095Medicaid
GAP00725554OtherRAILROAD MEDICARE
I08221Medicare UPIN
GAP00725554OtherRAILROAD MEDICARE
AL051554835LYLMedicare ID - Type Unspecified