Provider Demographics
NPI:1992746002
Name:TYNES, JOHN WAGNER (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WAGNER
Last Name:TYNES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 911057
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80291-1057
Mailing Address - Country:US
Mailing Address - Phone:888-269-7001
Mailing Address - Fax:303-764-6640
Practice Address - Street 1:14300 ORCHARD PKWY FL 3
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80023
Practice Address - Country:US
Practice Address - Phone:303-426-2580
Practice Address - Fax:303-426-2590
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA00067848207V00000X
CODR.0053014207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR112329OtherNORIDIAN MEDICARE
CAZZZ09988ZOtherBLUE SHIELD
160055143OtherRAILROAD MEDICARE
OR268688OtherOMAP MEDICAID
CA00A678480Medicaid
G91393Medicare UPIN
CA00A678480Medicaid