Provider Demographics
NPI:1851468987
Name:TYSON, MARTIN S (DO)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:S
Last Name:TYSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1500 N OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-3011
Mailing Address - Country:US
Mailing Address - Phone:417-326-6000
Mailing Address - Fax:417-328-6338
Practice Address - Street 1:1155 W PARKVIEW ST
Practice Address - Street 2:SUITE 1G
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-8279
Practice Address - Country:US
Practice Address - Phone:417-326-8700
Practice Address - Fax:417-328-6755
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001010358208600000X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO020049033OtherRAILROAD MEDICARE
MO431560263006OtherTRICARE
MO245315106Medicaid
MO245315106Medicaid
138880046Medicare Oscar/Certification
MO431560263006OtherTRICARE