Provider Demographics
NPI:1831185099
Name:LYTLE, ROBERT A (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:LYTLE
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 1:51 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-3109
Mailing Address - Country:US
Mailing Address - Phone:508-771-6447
Mailing Address - Fax:508-775-5104
Practice Address - Street 1:51 MAIN ST
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-3109
Practice Address - Country:US
Practice Address - Phone:508-771-6447
Practice Address - Fax:508-775-5104
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-23
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA54395207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3016455Medicaid
711397OtherTUFTS
M14824OtherBC/BS GRP #
MA9728112Medicaid
J04532OtherBC/BS IND #
711397OtherTUFTS
A57859Medicare UPIN
M14824Medicare ID - Type UnspecifiedGRP #