Provider Demographics
NPI:1912992082
Name:TOLLESON, THADDEUS REX (MD)
Entity Type:Individual
Prefix:
First Name:THADDEUS
Middle Name:REX
Last Name:TOLLESON
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 1:619 S FLEISHEL AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2004
Mailing Address - Country:US
Mailing Address - Phone:903-595-5514
Mailing Address - Fax:
Practice Address - Street 1:619 S FLEISHEL AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2004
Practice Address - Country:US
Practice Address - Phone:903-595-5514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6770207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX221985502OtherUNITED HEALTHCARE
TX8G7380OtherBCBS
TX8V5491OtherBCBS TRINITY
TX154221901Medicaid
TX7773430OtherAETNA
TX221985502OtherUNITED HEALTHCARE
TX8G7380OtherBCBS
TX8143B9Medicare PIN