Healthcare Provider Details

I. General information

NPI: 1356347561
Provider Name (Legal Business Name): LYLE E WADSWORTH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 03/27/2008
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: 386-740-9711
Mailing address:
  • Phone: 386-740-0224
  • Fax: 386-740-9711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberME30902
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: