MEDICARE: DR. KEITH LYSTON O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	TO3050	MO
2	152W00000X	Optometrist	046008572	IL

General Provider Information

NPI Number	:	1861614810
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEITH LYSTON O.D.

Provider Business Mailing Address
First Line	:	3300 GODFREY RD
Second Line	:
City	:	GODFREY
State	:	IL
Zip	:	62035-2558
Country	:	US
Telephone Number	:	618-466-8787
Fax Number	:	618-466-8787

Provider Business Practice Location Address
First Line	:	3300 GODFREY RD
Second Line	:
City	:	GODFREY
State	:	IL
Zip	:	62035-2558
Country	:	US
Telephone Number	:	618-466-8787
Fax Number	:	618-466-4703

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	02/19/2020

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Directions to “ DR. KEITH LYSTON O.D.” Practice Location

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