Provider Demographics
NPI:1881608644
Name:LYONS, DOUGLAS (DO)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:
Last Name:LYONS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MISSION ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT HALL
Mailing Address - State:ID
Mailing Address - Zip Code:83203-0717
Mailing Address - Country:US
Mailing Address - Phone:208-238-5427
Mailing Address - Fax:
Practice Address - Street 1:MISSION ROAD
Practice Address - Street 2:
Practice Address - City:FORT HALL
Practice Address - State:ID
Practice Address - Zip Code:83203-0717
Practice Address - Country:US
Practice Address - Phone:208-238-5456
Practice Address - Fax:208-238-5465
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-328207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E00625Medicare UPIN
ID8HE693Medicare ID - Type Unspecified