Provider Demographics
NPI:1851629448
Name:AYUSO, TISA A (DO)
Entity Type:Individual
Prefix:
First Name:TISA
Middle Name:A
Last Name:AYUSO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 PERRYRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-4697
Mailing Address - Country:US
Mailing Address - Phone:203-863-3944
Mailing Address - Fax:203-863-4690
Practice Address - Street 1:502 E 2ND ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-1913
Practice Address - Country:US
Practice Address - Phone:218-786-8376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-20
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0486922084P0804X
MN731362084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008001325Medicaid
CT008022626Medicaid
CT008039241Medicaid
CT004041000Medicaid
CT008022622Medicaid
CT008003745Medicaid
CT004082260Medicaid
CT008039745Medicaid
CT008001325Medicaid
CT008022626Medicaid
CT008039745Medicaid