Provider Demographics
NPI:1013339894
Name:TYSON, GEORGE WALTER (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:WALTER
Last Name:TYSON
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 1:25 HIGHWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-1526
Mailing Address - Country:US
Mailing Address - Phone:631-689-0570
Mailing Address - Fax:
Practice Address - Street 1:25 HIGHWOOD RD
Practice Address - Street 2:
Practice Address - City:SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-1526
Practice Address - Country:US
Practice Address - Phone:631-689-0570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-13
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY153174207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AT9643330OtherDEA