Provider Demographics
NPI:1851337687
Name:TYSON, JOHN P (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:P
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 1:1014 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:DENISON
Mailing Address - State:TX
Mailing Address - Zip Code:75020-2079
Mailing Address - Country:US
Mailing Address - Phone:903-416-6000
Mailing Address - Fax:903-416-6154
Practice Address - Street 1:1014 MEMORIAL DR
Practice Address - Street 2:1ST FLOOR
Practice Address - City:DENISON
Practice Address - State:TX
Practice Address - Zip Code:75020-2079
Practice Address - Country:US
Practice Address - Phone:903-416-6000
Practice Address - Fax:903-416-6154
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX01088207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX098755402Medicaid
TX098755402Medicaid
TX85Y225Medicare ID - Type Unspecified