Provider Demographics
NPI:1407861776
Name:LYELL, MARK S (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:LYELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2525 TELEPHONE RD
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39567-3202
Mailing Address - Country:US
Mailing Address - Phone:228-769-2069
Mailing Address - Fax:228-769-0406
Practice Address - Street 1:2525 TELEPHONE RD
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39567
Practice Address - Country:US
Practice Address - Phone:228-762-4483
Practice Address - Fax:228-769-0406
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS13231208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS10980353OtherCAQH
MS00119318Medicaid
MS340018613OtherRAILROAD MEDICARE
MS340000216Medicare ID - Type Unspecified