Provider Demographics
NPI:1699719021
Name:LYONS, MICHAEL GEORGE (DPM)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GEORGE
Last Name:LYONS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:
Other - Last Name:LYONS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PROFESSIONAL
Mailing Address - Street 1:1558 MONTEITH AVE
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632-7685
Mailing Address - Country:US
Mailing Address - Phone:662-449-3663
Mailing Address - Fax:662-449-3676
Practice Address - Street 1:1558 MONTEITH AVE
Practice Address - Street 2:
Practice Address - City:HERNANDO
Practice Address - State:MS
Practice Address - Zip Code:38632-7685
Practice Address - Country:US
Practice Address - Phone:662-449-3663
Practice Address - Fax:662-449-3676
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS80187213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01353580Medicaid
MS861168679OtherTAX ID
MS480000166Medicare PIN
MSV09884Medicare UPIN