Healthcare Provider Details

I. General information

NPI: 1689706319
Provider Name (Legal Business Name): DALE ANTHONY LYONS IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 02/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9168 2ND ST STE 200 COMMANDER SUBMARINE SQUADRON SIX MEDICAL
NORFOLK VA
23511-2323
US

IV. Provider business mailing address

1900 FLAGLER CT
VIRGINIA BEACH VA
23464-8935
US

V. Phone/Fax

Practice location:
  • Phone: 757-967-6175
  • Fax: 757-967-6905
Mailing address:
  • Phone: 808-783-9157
  • Fax: 757-967-6905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: