Provider Demographics
NPI:1144332438
Name:MOHR, LYLE ROWLAND (MD)
Entity type:Individual
Prefix:DR
First Name:LYLE
Middle Name:ROWLAND
Last Name:MOHR
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 1:980 3RD ST STE 100
Mailing Address - Street 2:
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-9469
Mailing Address - Country:US
Mailing Address - Phone:503-842-4033
Mailing Address - Fax:503-842-5044
Practice Address - Street 1:980 3RD ST STE 100
Practice Address - Street 2:
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-9469
Practice Address - Country:US
Practice Address - Phone:503-842-4033
Practice Address - Fax:503-842-5044
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10045208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR031468Medicaid
ORL250001OtherPACIFIC SOURCE
OR031468Medicaid
R0000BKFPNMedicare ID - Type Unspecified