Provider Demographics
NPI:1750327870
Name:TYSON, SAMUEL LESTER (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:LESTER
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 1:3810 N ELM ST
Mailing Address - Street 2:209
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27455
Mailing Address - Country:US
Mailing Address - Phone:336-282-3940
Mailing Address - Fax:336-282-8404
Practice Address - Street 1:3810 N ELM ST
Practice Address - Street 2:209
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27455
Practice Address - Country:US
Practice Address - Phone:336-282-3940
Practice Address - Fax:336-282-8404
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC38229207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890257XMedicaid
NC890257XMedicaid
NC213858BMedicare ID - Type Unspecified