Provider Demographics
NPI:1730126814
Name:TYMESON, MARTHA E (MD)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:E
Last Name:TYMESON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 VETERANS AVE
Mailing Address - Street 2:BEHAVIORAL HEALTH ROOM 511
Mailing Address - City:BATH
Mailing Address - State:NY
Mailing Address - Zip Code:14810-0810
Mailing Address - Country:US
Mailing Address - Phone:607-664-4300
Mailing Address - Fax:607-664-4320
Practice Address - Street 1:76 VETERANS AVE
Practice Address - Street 2:BEHAVIORAL HEALTH ROOM 511
Practice Address - City:BATH
Practice Address - State:NY
Practice Address - Zip Code:14810-0810
Practice Address - Country:US
Practice Address - Phone:607-664-4300
Practice Address - Fax:607-664-4320
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2369412084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02709979Medicaid
NY02709979Medicaid
F63918Medicare UPIN