Provider Demographics
NPI:1629047477
Name:TYSON, ROBERT WESLIE (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WESLIE
Last Name:TYSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:14275 MIDWAY RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-3614
Mailing Address - Country:US
Mailing Address - Phone:214-932-8029
Mailing Address - Fax:610-271-4245
Practice Address - Street 1:6750 W 52ND AVE
Practice Address - Street 2:SUITE F
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80002-3956
Practice Address - Country:US
Practice Address - Phone:720-898-3300
Practice Address - Fax:720-898-3333
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2015-04-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CO27968207ZP0102X, 207ZP0213X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZP0213XAllopathic & Osteopathic PhysiciansPathologyPediatric Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01279686Medicaid
NM37680761Medicaid
CO01279686Medicaid
E78670Medicare UPIN
COP00121215Medicare PIN