Basic Information
| Provider Information | |||||||||
| NPI: | 1295960805 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORTEZ | ||||||||
| FirstName: | LYLE | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8325 E SOUTHPORT RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462596805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178626609 | ||||||||
| FaxNumber: | 3177817373 | ||||||||
| Practice Location | |||||||||
| Address1: | 8325 E SOUTHPORT RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462596805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178626609 | ||||||||
| FaxNumber: | 3177817373 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2009 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 02004147A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 201092820 | 05 | IN | MEDICAID |