Provider Demographics
NPI:1790348076
Name:WALIEZER, TYSON DON (MD)
Entity Type:Individual
Prefix:
First Name:TYSON
Middle Name:DON
Last Name:WALIEZER
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 1:25909 CLARK ST
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-1622
Mailing Address - Country:US
Mailing Address - Phone:360-607-2703
Mailing Address - Fax:
Practice Address - Street 1:4160 JOHN R STREET
Practice Address - Street 2:HARPER PROFESSIONAL BUILDING, SUITE 615
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-745-4195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-22
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program