Provider Demographics
NPI:1306880778
Name:TYNES, JOSEPH R (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:R
Last Name:TYNES
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:PO BOX 52364
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71135-2364
Mailing Address - Country:US
Mailing Address - Phone:318-798-4539
Mailing Address - Fax:318-798-4601
Practice Address - Street 1:1500 LINE AVE STE 204
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4648
Practice Address - Country:US
Practice Address - Phone:318-300-4926
Practice Address - Fax:318-383-3951
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA025002207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1423611Medicaid
LAH83383Medicare UPIN
LA1423611Medicaid