Provider Demographics
NPI:1386780914
Name:OSTROW, LYLE W (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:LYLE
Middle Name:W
Last Name:OSTROW
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 N BROAD ST RM 1A
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-4106
Mailing Address - Country:US
Mailing Address - Phone:215-926-9022
Mailing Address - Fax:
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5103
Practice Address - Country:US
Practice Address - Phone:215-707-3040
Practice Address - Fax:215-707-8235
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD698792084N0400X
MDP196412084N0400X
PAMD4796062084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP19641OtherRESIDENT UMP NUMBER
MD036675700Medicaid
MDP19641OtherRESIDENT UMP NUMBER