Healthcare Provider Details

I. General information

NPI: 1467877670
Provider Name (Legal Business Name): JOHN PAUL LYTLE JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2014
Last Update Date: 02/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6729 204TH DR. NE
REDMOND WA
98053
US

IV. Provider business mailing address

P.O. BOX 3128
REDMOND WA
98073
US

V. Phone/Fax

Practice location:
  • Phone: 425-802-2556
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number36593
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number12151
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberH3111
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number87-359
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: