Healthcare Provider Details

I. General information

NPI: 1417035775
Provider Name (Legal Business Name): BENJAMIN LYE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 05/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 W 20TH ST
JACKSONVILLE FL
32254-1703
US

IV. Provider business mailing address

PO BOX 19189
JACKSONVILLE FL
32245-9189
US

V. Phone/Fax

Practice location:
  • Phone: 904-695-9145
  • Fax: 904-695-2465
Mailing address:
  • Phone: 904-743-1883
  • Fax: 904-743-5109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME36271
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: