Healthcare Provider Details

I. General information

NPI: 1346980919
Provider Name (Legal Business Name): JACK TYLER LYDEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2022
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4160 TEMESCAL CANYON RD
CORONA CA
92883-4625
US

IV. Provider business mailing address

4160 TEMESCAL CANYON RD
CORONA CA
92883-4625
US

V. Phone/Fax

Practice location:
  • Phone: 858-279-1223
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number209112
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: