Healthcare Provider Details

I. General information

NPI: 1922085901
Provider Name (Legal Business Name): ROBERT LEE LYCKSELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 02/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

231 SE BARRINGTON DRIVE SUITE 209
OAK HARBOR WA
98277
US

IV. Provider business mailing address

231 SE BARRINGTON DRIVE SUITE 209
OAK HARBOR WA
98277
US

V. Phone/Fax

Practice location:
  • Phone: 360-679-3161
  • Fax: 360-679-1741
Mailing address:
  • Phone: 360-679-3161
  • Fax: 360-679-1741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00020054
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: