Provider Demographics
NPI:1659323848
Name:TYSON, SAM TILDEN (MD)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:TILDEN
Last Name:TYSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:7231 HUNTERS RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-5207
Mailing Address - Country:US
Mailing Address - Phone:915-877-3151
Mailing Address - Fax:915-877-5346
Practice Address - Street 1:6898 DONIPHAN DR
Practice Address - Street 2:
Practice Address - City:CANUTILLO
Practice Address - State:TX
Practice Address - Zip Code:79835-5401
Practice Address - Country:US
Practice Address - Phone:915-877-3151
Practice Address - Fax:915-877-5346
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXH2185207P00000X, 208D00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1383929-10Medicaid
TX1383929-07Medicaid
TX1383929-07Medicaid
TX0075BFMedicare ID - Type UnspecifiedMEDICARE TEXAS