Healthcare Provider Details

I. General information

NPI: 1659323848
Provider Name (Legal Business Name): SAM TILDEN TYSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 09/10/2020
Certification Date: 09/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6898 DONIPHAN DR
CANUTILLO TX
79835-5401
US

IV. Provider business mailing address

7231 HUNTERS RIDGE DR
DALLAS TX
75248-5207
US

V. Phone/Fax

Practice location:
  • Phone: 915-877-3151
  • Fax: 915-877-5346
Mailing address:
  • Phone: 915-877-3151
  • Fax: 915-877-5346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberH2185
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberH2185
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberH2185
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: