1275517005 NPI number — DR. DEBORAH K. TYSON PHD

Table of content: DR. DEBORAH K. TYSON PHD (NPI 1275517005)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275517005 NPI number — DR. DEBORAH K. TYSON PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TYSON
Provider First Name:
DEBORAH
Provider Middle Name:
K.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RODRIGUEZ
Provider Other First Name:
DEBORAH
Provider Other Middle Name:
TYSON
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1275517005
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9021 SW 94 STREET
Provider Second Line Business Mailing Address:
APT 208
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33176-2311
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-595-8225
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7700 NORTH KENDALL DRIVE
Provider Second Line Business Practice Location Address:
SUITE 413
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33156-7565
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-595-8225
Provider Business Practice Location Address Fax Number:
305-596-6947
Provider Enumeration Date:
12/05/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PY4181 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC1900X , with the licence number: PY4181 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 73459 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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