Healthcare Provider Details

I. General information

NPI: 1679957427
Provider Name (Legal Business Name): ROBERT LYSTRUP MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2015
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2260 N ROSEMONT BLVD
TUCSON AZ
85712-2137
US

IV. Provider business mailing address

4801 E BROADWAY BLVD STE 251
TUCSON AZ
85711-2700
US

V. Phone/Fax

Practice location:
  • Phone: 520-318-1033
  • Fax: 520-318-1338
Mailing address:
  • Phone: 520-327-0460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number58675
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberLL2644
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number58675
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: