Provider Demographics
NPI:1487708624
Name:LYON, MALCOLM KENT (DO)
Entity type:Individual
Prefix:DR
First Name:MALCOLM
Middle Name:KENT
Last Name:LYON
Suffix:
Gender:M
Credentials:DO
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 630810
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75963-0810
Mailing Address - Country:US
Mailing Address - Phone:936-559-0235
Mailing Address - Fax:
Practice Address - Street 1:1204 N MOUND ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-4027
Practice Address - Country:US
Practice Address - Phone:936-568-8448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF9762207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX80M725Medicare ID - Type Unspecified
TXA67362Medicare UPIN