Healthcare Provider Details

I. General information

NPI: 1417123829
Provider Name (Legal Business Name): JAYME R TISHON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2008
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 MEDICAL CENTER PT
COLORADO SPRINGS CO
80907-5788
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 719-473-6155
  • Fax:
Mailing address:
  • Phone: 719-538-2900
  • Fax: 719-538-2990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number0101251992
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberDR.0063222
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: