Provider Demographics
NPI:1346266269
Name:TYSON, BRIAN M (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:M
Last Name:TYSON
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 1:420 SUNFLOWER CT
Mailing Address - Street 2:
Mailing Address - City:BRAWLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92227-3243
Mailing Address - Country:US
Mailing Address - Phone:760-592-4351
Mailing Address - Fax:
Practice Address - Street 1:2026 N IMPERIAL AVE STE C
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-1607
Practice Address - Country:US
Practice Address - Phone:760-592-4351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA88297208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A882970OtherBLUE SHIELD
CA00A882970OtherBCBS OF CA
CA00A882970OtherBCBS OF CA
CA00A882970OtherBLUE SHIELD
CAWA88297BMedicare PIN