Provider Demographics
NPI:1821069196
Name:JONES, TYRE K IV
Entity Type:Individual
Prefix:
First Name:TYRE
Middle Name:K
Last Name:JONES
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1579 WEDGEWOOD PL
Mailing Address - Street 2:
Mailing Address - City:ESSEXVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48732-3203
Mailing Address - Country:US
Mailing Address - Phone:989-891-0598
Mailing Address - Fax:
Practice Address - Street 1:1579 WEDGEWOOD PL
Practice Address - Street 2:
Practice Address - City:ESSEXVILLE
Practice Address - State:MI
Practice Address - Zip Code:48732
Practice Address - Country:US
Practice Address - Phone:989-891-0598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010614002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4409112Medicaid
MI4409112Medicaid