Provider Demographics
NPI:1306941083
Name:AFFLECK, TY PRESTON (MD)
Entity type:Individual
Prefix:MR
First Name:TY
Middle Name:PRESTON
Last Name:AFFLECK
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 1:1255 N DUTTON AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-4663
Mailing Address - Country:US
Mailing Address - Phone:707-546-9400
Mailing Address - Fax:707-546-9464
Practice Address - Street 1:1255 N DUTTON AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4663
Practice Address - Country:US
Practice Address - Phone:707-546-9400
Practice Address - Fax:707-546-9464
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG073843207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E71942Medicare UPIN
CABG667ZMedicare PIN