Healthcare Provider Details

I. General information

NPI: 1083679062
Provider Name (Legal Business Name): DWIGHT H LYSNE MD, MDIV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 09/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 S 16TH ST
WILMINGTON NC
28401-4924
US

IV. Provider business mailing address

7212 OYSTER LN
WILMINGTON NC
28411-7132
US

V. Phone/Fax

Practice location:
  • Phone: 877-456-6729
  • Fax: 910-399-3928
Mailing address:
  • Phone: 910-465-1935
  • Fax: 910-399-3928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number5512
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number28290
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number200301378
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier94D78LY
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerMNBC/BS
# 2
Identifier15992
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer
# 3
Identifier937078100
Identifier TypeMEDICAID
Identifier StateMN
Identifier Issuer
# 4
Identifier19977
Identifier TypeOTHER
Identifier StateND
Identifier IssuerNDBCBS
# 5
Identifier260045000
Identifier TypeOTHER
Identifier State
Identifier IssuerRAILROAD MEDICARE
# 6
Identifier891378J
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: