Provider Demographics
NPI:1063625317
Name:BREEDING, LYLE G (MD)
Entity type:Individual
Prefix:
First Name:LYLE
Middle Name:G
Last Name:BREEDING
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:11373 CORTEZ BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-5414
Mailing Address - Country:US
Mailing Address - Phone:352-597-3444
Mailing Address - Fax:352-597-0117
Practice Address - Street 1:11373 CORTEZ BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-5414
Practice Address - Country:US
Practice Address - Phone:352-597-3444
Practice Address - Fax:352-597-0117
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2018-02-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MOR9N912086S0129X, 208600000X
FLME102374261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202943122Medicaid
MO202943122Medicaid
C54793Medicare UPIN