Healthcare Provider Details

I. General information

NPI: 1184660664
Provider Name (Legal Business Name): REGGIE DUANE LYELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 FEDERAL DR NW SUITE 200
CORYDON IN
47112-3070
US

IV. Provider business mailing address

PO BOX 455
CORYDON IN
47112-0455
US

V. Phone/Fax

Practice location:
  • Phone: 812-738-4155
  • Fax: 812-738-6104
Mailing address:
  • Phone: 812-738-4155
  • Fax: 812-738-6104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01042535
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: