Provider Demographics
NPI:1861567208
Name:LYLES, MICHAEL ROY SR
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ROY
Last Name:LYLES
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4574 KETTERING DR NE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-3189
Mailing Address - Country:US
Mailing Address - Phone:770-552-1401
Mailing Address - Fax:
Practice Address - Street 1:11111 HOUZE RD
Practice Address - Street 2:STE. 320
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-5663
Practice Address - Country:US
Practice Address - Phone:770-993-0051
Practice Address - Fax:770-993-0052
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA290322084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA26BDGJGMedicare ID - Type UnspecifiedHCFA #