Provider Demographics
NPI:1417030131
Name:TYSON, JAMES W (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:W
Last Name:TYSON
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 1:1125 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:BREVARD
Mailing Address - State:NC
Mailing Address - Zip Code:28712-9515
Mailing Address - Country:US
Mailing Address - Phone:828-862-6218
Mailing Address - Fax:828-877-5054
Practice Address - Street 1:123 GALLIMORE RD
Practice Address - Street 2:
Practice Address - City:BREVARD
Practice Address - State:NC
Practice Address - Zip Code:28712-9520
Practice Address - Country:US
Practice Address - Phone:828-862-6218
Practice Address - Fax:828-877-5054
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC16164207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8984450Medicaid
NC01-70391OtherUNITED HEALTHCARE
NC0637660001OtherPALMETTO GOV. SERVICES
NC84450OtherBLUE CROSS BLUE SHIELD
NC01-70391OtherUNITED HEALTHCARE
NC0637660001OtherPALMETTO GOV. SERVICES