Provider Demographics
NPI:1710982061
Name:COBB, TYSON (MD)
Entity Type:Individual
Prefix:DR
First Name:TYSON
Middle Name:
Last Name:COBB
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 1:1140 W LA VETA AVE
Mailing Address - Street 2:SUITE 640
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868
Mailing Address - Country:US
Mailing Address - Phone:714-564-3300
Mailing Address - Fax:714-564-3318
Practice Address - Street 1:1140 W LA VETA AVE
Practice Address - Street 2:SUITE 640
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868
Practice Address - Country:US
Practice Address - Phone:714-564-3300
Practice Address - Fax:949-231-5112
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-14
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC35334207RI0011X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADB3373OtherRAILROAD MEDICARE
CAW13988AOtherMEDICARE PTAN
CAW13988OtherMEDICARE PTAN
CA060065322OtherRAILROAD MEDICARE
CAW13988AOtherMEDICARE PTAN
CAHW13988Medicare PIN
CAA35946Medicare UPIN
CADB3373OtherRAILROAD MEDICARE
CAHW13988AMedicare PIN