Healthcare Provider Details

I. General information

NPI: 1487751749
Provider Name (Legal Business Name): ROBERT CHARLES LYELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 12/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3798 JANES ROAD SUITE 9
ARCATA CA
95521-4745
US

IV. Provider business mailing address

3798 JANES ROAD SUITE 9
ARCATA CA
95521-4745
US

V. Phone/Fax

Practice location:
  • Phone: 707-826-7080
  • Fax: 707-826-7119
Mailing address:
  • Phone: 707-826-7080
  • Fax: 707-826-7119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberG76911
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: