Healthcare Provider Details

I. General information

NPI: 1053504308
Provider Name (Legal Business Name): MARK EDWARD LYTLE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2007
Last Update Date: 01/27/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5149 N 9TH AVE SUITE 120
PENSACOLA FL
32504-8756
US

IV. Provider business mailing address

PO BOX 11982
PENSACOLA FL
32524-1982
US

V. Phone/Fax

Practice location:
  • Phone: 850-479-1805
  • Fax: 850-479-1829
Mailing address:
  • Phone: 850-479-1805
  • Fax: 850-479-1829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberME125365
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: