Provider Demographics
NPI:1912938192
Name:LYLE, LURTON B (MD)
Entity type:Individual
Prefix:DR
First Name:LURTON
Middle Name:B
Last Name:LYLE
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 1:364 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:CLINTWOOD
Mailing Address - State:VA
Mailing Address - Zip Code:24228
Mailing Address - Country:US
Mailing Address - Phone:276-926-0200
Mailing Address - Fax:276-926-6675
Practice Address - Street 1:364 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:CLINTWOOD
Practice Address - State:VA
Practice Address - Zip Code:24228
Practice Address - Country:US
Practice Address - Phone:276-926-0200
Practice Address - Fax:276-926-6675
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101016773207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010203848Medicaid
VA1912938192Medicaid
VA009941D11Medicare PIN
VA1912938192Medicaid
VA010203848Medicaid
VATN-0106OtherJOHN DEERE
VAC09011Medicare UPIN
VA1912938192Medicaid
VA009941D11Medicare PIN