Provider Demographics
NPI:1932201423
Name:LYONS, ALFRED GORDON (MD)
Entity Type:Individual
Prefix:
First Name:ALFRED
Middle Name:GORDON
Last Name:LYONS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:A.
Other - Middle Name:GORDON
Other - Last Name:LYONS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 23666
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3666
Mailing Address - Country:US
Mailing Address - Phone:601-200-4880
Mailing Address - Fax:601-200-5929
Practice Address - Street 1:970 LAKELAND DR
Practice Address - Street 2:45
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4635
Practice Address - Country:US
Practice Address - Phone:601-200-4690
Practice Address - Fax:601-200-4698
Is Sole Proprietor?:No
Enumeration Date:2006-09-04
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10603174400000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP01237614OtherRAILROAD MEDICARE
MS00115787Medicaid
MS311183YJ9XMedicare PIN