Provider Demographics
NPI:1952300592
Name:TISON, JOSEPH BARLIN (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:BARLIN
Last Name:TISON
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 14005
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92863-1405
Mailing Address - Country:US
Mailing Address - Phone:714-571-5000
Mailing Address - Fax:714-571-5055
Practice Address - Street 1:431 S BATAVIA ST
Practice Address - Street 2:STE. 103
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3936
Practice Address - Country:US
Practice Address - Phone:714-538-6731
Practice Address - Fax:714-771-8369
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA380332085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
053304CA28516OtherTRAILBLAZER
00A380330 159OtherCALOPTIMA
300035669OtherRAILROAD MEDICARE
00A380330OtherBLUE SHIELD OF CA
CA00A380330Medicaid
00A380330OtherBLUE SHIELD OF CA
WA38033DMedicare PIN
A28516Medicare UPIN
053304CA28516OtherTRAILBLAZER
WA38033HMedicare PIN