Provider Demographics
NPI:1649265117
Name:TYSON, JOHN WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:WILLIAM
Last Name:TYSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:11945 SAN JOSE BLVD
Mailing Address - Street 2:STE 300
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-1613
Mailing Address - Country:US
Mailing Address - Phone:904-396-1725
Mailing Address - Fax:904-399-1717
Practice Address - Street 1:4012 N 9TH AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2824
Practice Address - Country:US
Practice Address - Phone:850-444-4777
Practice Address - Fax:850-434-3387
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME80209208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL059270300Medicaid
FL059270300Medicaid
FLG59363Medicare UPIN