Healthcare Provider Details

I. General information

NPI: 1770523391
Provider Name (Legal Business Name): KENNETH P. LYONS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20162 SW BIRCH ST SUITE 150
NEWPORT BEACH CA
92660-0787
US

IV. Provider business mailing address

20162 SW BIRCH ST SUITE 150
NEWPORT BEACH CA
92660-0787
US

V. Phone/Fax

Practice location:
  • Phone: 949-221-1700
  • Fax: 949-221-1704
Mailing address:
  • Phone: 949-221-1700
  • Fax: 949-221-1704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License NumberG12843
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: