Provider Demographics
NPI:1417277435
Name:TYO, STEPHANIE RENEE (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RENEE
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:PO BOX 844273
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4273
Mailing Address - Country:US
Mailing Address - Phone:903-535-9041
Mailing Address - Fax:903-533-0726
Practice Address - Street 1:928 N GLENWOOD BLVD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-5055
Practice Address - Country:US
Practice Address - Phone:903-535-9041
Practice Address - Fax:903-533-0726
Is Sole Proprietor?:No
Enumeration Date:2010-06-02
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP7365207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine