Healthcare Provider Details

I. General information

NPI: 1932201423
Provider Name (Legal Business Name): ALFRED GORDON LYONS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: A. GORDON LYONS M.D.

II. Dates (important events)

Enumeration Date: 09/04/2006
Last Update Date: 10/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

970 LAKELAND DR 45
JACKSON MS
39216-4635
US

IV. Provider business mailing address

PO BOX 23666
JACKSON MS
39225-3666
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-4690
  • Fax: 601-200-4698
Mailing address:
  • Phone: 601-200-4880
  • Fax: 601-200-5929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number10603
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number10603
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: