Provider Demographics
NPI:1609851153
Name:TYNES, DONALD J (MD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:J
Last Name:TYNES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:DON
Other - Middle Name:J
Other - Last Name:TYNES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:756 PIPESTONE ST
Mailing Address - Street 2:
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022-4845
Mailing Address - Country:US
Mailing Address - Phone:269-926-8535
Mailing Address - Fax:269-926-8528
Practice Address - Street 1:756 PIPESTONE ST
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-4845
Practice Address - Country:US
Practice Address - Phone:269-926-8535
Practice Address - Fax:269-926-8528
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-07
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301065652207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI06103AOtherBERRIEN HEALTH PLAN
MI7338232OtherAETNA
MI11-01-11-04-82OtherBCBS
MIOPO3540OtherMEDICARE GROUP BUSINESS NUMBER
MI11583OtherHEATH PLAN OF MICHIGAN
MI4662247-10Medicaid
MI412153406100OtherCOMMUNITY CHOICE OF MI
MI4662247-10Medicaid