Healthcare Provider Details

I. General information

NPI: 1790744704
Provider Name (Legal Business Name): JONATHAN ERIC THYGESON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JOHN E THYGESON MD

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 12/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 UNIVERSITY AVENUE
SACRAMENTO CA
95825
US

IV. Provider business mailing address

755 UNIVERSITY AVENUE
SACRAMENTO CA
95825
US

V. Phone/Fax

Practice location:
  • Phone: 916-924-8754
  • Fax: 916-924-1739
Mailing address:
  • Phone: 916-924-8754
  • Fax: 916-924-1739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA75063
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: