Provider Demographics
NPI:1114366788
Name:STOCK, TYSON (DO)
Entity type:Individual
Prefix:
First Name:TYSON
Middle Name:
Last Name:STOCK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 N HALSTED ST STE 401
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-9268
Mailing Address - Country:US
Mailing Address - Phone:773-935-5985
Mailing Address - Fax:773-935-5478
Practice Address - Street 1:3000 N HALSTED ST STE 401
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-9268
Practice Address - Country:US
Practice Address - Phone:773-935-5985
Practice Address - Fax:773-935-5478
Is Sole Proprietor?:No
Enumeration Date:2013-06-17
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036140162207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine