Provider Demographics
NPI:1457433401
Name:TYSZKOWSKI, KRISTEN A (MD)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:A
Last Name:TYSZKOWSKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 CALVERT PL
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02835-1514
Mailing Address - Country:US
Mailing Address - Phone:401-341-0445
Mailing Address - Fax:
Practice Address - Street 1:30 W 63RD ST APT 16H
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-7116
Practice Address - Country:US
Practice Address - Phone:401-341-0445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301074435207RG0300X, 2084P0800X, 207R00000X
NY2727962084P0805X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06994449Medicaid