Provider Demographics
NPI:1114916350
Name:LYSTER, MICHAEL T (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:LYSTER
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 1:2400 S AVENUE A
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-7127
Mailing Address - Country:US
Mailing Address - Phone:928-344-2000
Mailing Address - Fax:
Practice Address - Street 1:2375 S RIDGEVIEW DR
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-8868
Practice Address - Country:US
Practice Address - Phone:928-317-2518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036081248207RH0003X
AZ42959207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036081248Medicaid
AZ505784Medicaid
ILL56904Medicare PIN
IL900001507Medicare PIN
ILL56365Medicare PIN
AZZ136915Medicare PIN
F49022Medicare UPIN
AZ505784Medicaid
ILL62124Medicare PIN