Provider Demographics
NPI:1235251117
Name:LANDEZA, TYSON C (MD)
Entity Type:Individual
Prefix:
First Name:TYSON
Middle Name:C
Last Name:LANDEZA
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 1:13352 HAWTHORNE BLVD
Mailing Address - Street 2:STE. B
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-5805
Mailing Address - Country:US
Mailing Address - Phone:310-679-1890
Mailing Address - Fax:310-679-1898
Practice Address - Street 1:13352 HAWTHORNE BLVD
Practice Address - Street 2:STE. B
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-5805
Practice Address - Country:US
Practice Address - Phone:310-679-1890
Practice Address - Fax:310-679-1898
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA92168208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA92168OtherMEDICAL LICENSE #
CA00A921680Medicaid