Basic Information
| Provider Information | |||||||||
| NPI: | 1780716563 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VICKI J LYONS MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4403 HARRISON BLVD | ||||||||
| Address2: | SUITE 4640 | ||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844033271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013874850 | ||||||||
| FaxNumber: | 8013874855 | ||||||||
| Practice Location | |||||||||
| Address1: | 4403 HARRISON BLVD | ||||||||
| Address2: | SUITE 4640 | ||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844033271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013874850 | ||||||||
| FaxNumber: | 8013874855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2007 | ||||||||
| LastUpdateDate: | 10/16/2015 | ||||||||
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| AuthorizedOfficialLastName: | LYONS | ||||||||
| AuthorizedOfficialFirstName: | VICKI | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8013874850 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207KA0200X | 272784-1205 | UT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology | Allergy |
ID Information
| ID | Type | State | Issuer | Description | DA3586 | 01 | UT | RAILROAD MEDICARE | OTHER |