Provider Demographics
NPI:1174620512
Name:BOX, LYNDON C (MD)
Entity type:Individual
Prefix:DR
First Name:LYNDON
Middle Name:C
Last Name:BOX
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 742941
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2941
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1906 FAIRVIEW AVE STE 230
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-5432
Practice Address - Country:US
Practice Address - Phone:208-459-4667
Practice Address - Fax:208-442-6520
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91308207R00000X, 207RC0000X
GA061212207RC0000X
IDM11945207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2813611-00Medicaid
ID20002923Medicare PIN
FL2813611-00Medicaid
FLP00665618Medicare PIN
GA511I060260Medicare PIN