Provider Demographics
NPI:1124257035
Name:LYLES, NATASHA G (OD)
Entity type:Individual
Prefix:DR
First Name:NATASHA
Middle Name:G
Last Name:LYLES
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 COMMERCE BLVD
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:KY
Mailing Address - Zip Code:42025-1112
Mailing Address - Country:US
Mailing Address - Phone:270-252-3937
Mailing Address - Fax:
Practice Address - Street 1:140 COMMERCE BLVD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:KY
Practice Address - Zip Code:42025-1112
Practice Address - Country:US
Practice Address - Phone:270-252-3937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-13
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1768DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000680886OtherANTHEM BCBS
KYP00918684OtherRAILROAD MEDICARE
KY000000624689OtherANTHEM BCBS
KY7100081610Medicaid
KY000000690650OtherANTHEM BCBS
KY4644660001Medicare NSC
KY0632503Medicare PIN
KYP00918684OtherRAILROAD MEDICARE
KY000000680886OtherANTHEM BCBS