Provider Demographics
NPI:1295837110
Name:SCHWIESOW, TYSON KARL (MD)
Entity Type:Individual
Prefix:
First Name:TYSON
Middle Name:KARL
Last Name:SCHWIESOW
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 1:1087 W MASON STREET
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-1859
Mailing Address - Country:US
Mailing Address - Phone:920-499-3102
Mailing Address - Fax:920-499-9636
Practice Address - Street 1:1087 W MASON STREET
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-1859
Practice Address - Country:US
Practice Address - Phone:920-499-3102
Practice Address - Fax:920-499-9636
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41186020207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34222000Medicaid
WI34222000Medicaid