Provider Demographics
NPI:1508857491
Name:TYSON, FARRELL C II (MD)
Entity Type:Individual
Prefix:DR
First Name:FARRELL
Middle Name:C
Last Name:TYSON
Suffix:II
Gender:M
Credentials:MD
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Mailing Address - Street 1:4120 DEL PRADO BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904
Mailing Address - Country:US
Mailing Address - Phone:239-542-2020
Mailing Address - Fax:239-541-1492
Practice Address - Street 1:4120 DEL PRADO BLVD S
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-7165
Practice Address - Country:US
Practice Address - Phone:239-542-2020
Practice Address - Fax:239-541-0175
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2020-08-28
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Provider Licenses
StateLicense IDTaxonomies
FLME81910207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264385500Medicaid
FL264385500Medicaid
FLH39053Medicare UPIN