Provider Demographics
NPI:1710915368
Name:HYSON, MORTON I (MD)
Entity Type:Individual
Prefix:
First Name:MORTON
Middle Name:I
Last Name:HYSON
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 1:701 SHADOW LN STE 170
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4178
Mailing Address - Country:US
Mailing Address - Phone:702-387-1757
Mailing Address - Fax:702-387-2006
Practice Address - Street 1:701 SHADOW LANE #170
Practice Address - Street 2:
Practice Address - City:LV
Practice Address - State:NV
Practice Address - Zip Code:89106-4178
Practice Address - Country:US
Practice Address - Phone:702-387-1757
Practice Address - Fax:702-387-2006
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6062174400000X, 2084N0400X
CA890912084N0400X
CODR.00522242084N0400X
IDM-121912084N0400X
TXG44772084N0400X
FLME1108252084N0400X
AZ497002084N0400X
IL0361400932084N0400X
MTMED-PHYS-LIC-413392084N0400X
NMTM2016-01322084N0400X
UT8581120-12052084N0400X
WY9571A2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002019047Medicaid
CO562281ZY25Medicare PIN
NV002019047Medicaid
AZZ199484Medicare PIN
NVVMD6062Medicare ID - Type Unspecified
NVB23677Medicare UPIN
AZZ199485Medicare PIN