Provider Demographics
NPI:1972669653
Name:TYE, WILLIAM G III
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:G
Last Name:TYE
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 NW SAINT JAMES DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-1291
Mailing Address - Country:US
Mailing Address - Phone:772-249-9450
Mailing Address - Fax:772-249-0701
Practice Address - Street 1:201 NW SAINT JAMES DR
Practice Address - Street 2:SUITE C
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-1291
Practice Address - Country:US
Practice Address - Phone:772-249-9450
Practice Address - Fax:772-249-0701
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP1293171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC0648OtherBLUECROSS BLUESHIELD