Healthcare Provider Details

I. General information

NPI: 1639113665
Provider Name (Legal Business Name): SYDNEY L TYSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 09/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 S LINCOLN AVE
VINELAND NJ
08361-7802
US

IV. Provider business mailing address

251 S LINCOLN AVE
VINELAND NJ
08361-7802
US

V. Phone/Fax

Practice location:
  • Phone: 856-691-8188
  • Fax: 856-691-0421
Mailing address:
  • Phone: 856-691-8188
  • Fax: 856-691-0421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number25MA05947000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: