Provider Demographics
NPI:1205843398
Name:TYO, CARISSA (MD)
Entity Type:Individual
Prefix:DR
First Name:CARISSA
Middle Name:
Last Name:TYO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 S. WOOD STREET
Mailing Address - Street 2:M/C 724
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612
Mailing Address - Country:US
Mailing Address - Phone:312-996-5719
Mailing Address - Fax:312-413-0289
Practice Address - Street 1:1740 W TAYLOR ST
Practice Address - Street 2:DEPT 3466
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7232
Practice Address - Country:US
Practice Address - Phone:312-996-8177
Practice Address - Fax:312-413-0289
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112405207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILI26423Medicare UPIN