Healthcare Provider Details

I. General information

NPI: 1760877633
Provider Name (Legal Business Name): WILLIS HUGHES LYFORD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2015
Last Update Date: 03/09/2023
Certification Date: 03/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAL MEDICAL CENTER SAN DIEGO 34800 BOB WILSON DR
SAN DIEGO CA
92134-0001
US

IV. Provider business mailing address

3255 ISLA VISTA DR
SAN DIEGO CA
92105-2929
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-9660
  • Fax:
Mailing address:
  • Phone: 907-947-4821
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number1760877633
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberC183093
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: