Healthcare Provider Details

I. General information

NPI: 1205018207
Provider Name (Legal Business Name): LYLE E WADSWORTH MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2007
Last Update Date: 03/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 N BOUNDARY AVE STE 102
DELAND FL
32720-3173
US

IV. Provider business mailing address

890 N BOUNDARY AVE STE 102
DELAND FL
32720-3173
US

V. Phone/Fax

Practice location:
  • Phone: 386-740-0224
  • Fax:
Mailing address:
  • Phone: 386-740-0224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME30902
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberME30902
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License NumberME30902
License Number StateFL

VIII. Authorized Official

Name: DR. LYLE E. WADSWORTH
Title or Position: PRESIDENT
Credential: MD
Phone: 386-740-0224