Provider Demographics
NPI:1841491370
Name:LYLES, JOHNNIE (MD, MBA)
Entity type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:
Last Name:LYLES
Suffix:
Gender:M
Credentials:MD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2908 OAK LAKE BLVD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-7703
Mailing Address - Country:US
Mailing Address - Phone:704-567-8233
Mailing Address - Fax:
Practice Address - Street 1:2908 OAK LAKE BLVD
Practice Address - Street 2:SUITE 205
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-7703
Practice Address - Country:US
Practice Address - Phone:704-567-8233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2009-00568208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1841491370OtherUNITED HEALTH CARE
NC1841491370OtherBCBSNC
NC1841491370OtherHEALTHNET/TRICARE
NC1841491370Medicaid
NC1841491370OtherMEDCOST
NC1841491370OtherCOVENTRY/WELLPATH
NC1841491370OtherAETNA
NC7014253OtherCIGNA
NC1841491370OtherMEDCOST