1851629448 NPI number — TISA A AYUSO D.O.

Table of content: TISA A AYUSO D.O. (NPI 1851629448)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851629448 NPI number — TISA A AYUSO D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AYUSO
Provider First Name:
TISA
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1851629448
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/24/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 PERRYRIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENWICH
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06830-4697
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-863-3944
Provider Business Mailing Address Fax Number:
203-863-4690

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
502 E 2ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55805-1913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-786-8376
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/20/2009

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: 2084P0804X , with the licence number:  048692 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0804X , with the licence number: 73136 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 008001325 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 008022626 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 008039241 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004041000 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 008022622 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 008003745 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004082260 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 008039745 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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