Provider Demographics
NPI:1225132665
Name:MCSWEENEY - TYSON, DEIDRE L (MD)
Entity Type:Individual
Prefix:DR
First Name:DEIDRE
Middle Name:L
Last Name:MCSWEENEY - TYSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:DEIDRE
Other - Middle Name:L
Other - Last Name:TYSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:101 WILLIAM H JOHNSON ST STE 420
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29506-2769
Mailing Address - Country:US
Mailing Address - Phone:843-777-5701
Mailing Address - Fax:843-777-7320
Practice Address - Street 1:101 WILLIAM H JOHNSON ST STE 420
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2769
Practice Address - Country:US
Practice Address - Phone:843-777-5701
Practice Address - Fax:843-777-7320
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC83712208000000X, 2080P0205X
CACA-G160210208000000X, 2080P0205X
VA0101048009208000000X, 2080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6720358Medicaid
370001228Medicare ID - Type Unspecified
F76932Medicare UPIN