Healthcare Provider Details

I. General information

NPI: 1255328746
Provider Name (Legal Business Name): JOHN H LYONS III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 07/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 HARRISON BLVD
OGDEN UT
84403-4303
US

IV. Provider business mailing address

4650 HARRISON BLVD
OGDEN UT
84403-4303
US

V. Phone/Fax

Practice location:
  • Phone: 801-479-4621
  • Fax: 801-476-2670
Mailing address:
  • Phone: 801-479-4621
  • Fax: 801-476-2670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2723891205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: