Provider Demographics
NPI:1942295092
Name:TISO, ROBERT L (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:TISO
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:PO BOX 510
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13214-0510
Mailing Address - Country:US
Mailing Address - Phone:315-703-3484
Mailing Address - Fax:315-703-3487
Practice Address - Street 1:5496 EAST TAFT ROAD
Practice Address - Street 2:
Practice Address - City:NORTH SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212
Practice Address - Country:US
Practice Address - Phone:315-552-6700
Practice Address - Fax:315-552-6701
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171318208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01196510Medicaid
E47504Medicare UPIN
NYCC2593Medicare PIN