Provider Demographics
NPI:1639113665
Name:TYSON, SYDNEY L (MD)
Entity Type:Individual
Prefix:
First Name:SYDNEY
Middle Name:L
Last Name:TYSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 S LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08361-7802
Mailing Address - Country:US
Mailing Address - Phone:856-691-8188
Mailing Address - Fax:856-691-0421
Practice Address - Street 1:251 S LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08361-7802
Practice Address - Country:US
Practice Address - Phone:856-691-8188
Practice Address - Fax:856-691-0421
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05947000207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5536201Medicaid
720158MT1Medicare ID - Type Unspecified
NJ5536201Medicaid