Provider Demographics
NPI:1467486852
Name:TYSZKO, ROBERT MARC
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:MARC
Last Name:TYSZKO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 WILTON RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:PETERBOROUGH
Mailing Address - State:NH
Mailing Address - Zip Code:03458-1749
Mailing Address - Country:US
Mailing Address - Phone:603-924-9591
Mailing Address - Fax:603-924-9593
Practice Address - Street 1:129 WILTON RD
Practice Address - Street 2:SUITE A
Practice Address - City:PETERBOROUGH
Practice Address - State:NH
Practice Address - Zip Code:03458-1749
Practice Address - Country:US
Practice Address - Phone:603-924-9591
Practice Address - Fax:603-924-9593
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH726152W00000X, 152WC0802X
MA3796152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30354215Medicaid
NH09Y003479NH04OtherANTHEM
NH7823073OtherCIGNA
NHRE668001Medicare PIN
NH09Y003479NH04OtherANTHEM