Provider Demographics
NPI:1174739460
Name:HARDY, TYRONE LESLIE (MD)
Entity type:Individual
Prefix:
First Name:TYRONE
Middle Name:LESLIE
Last Name:HARDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5565 GROSSMONT CENTER DR
Mailing Address - Street 2:BLDG. 1, SUITE 119
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3020
Mailing Address - Country:US
Mailing Address - Phone:619-464-3153
Mailing Address - Fax:619-464-3429
Practice Address - Street 1:5565 GROSSMONT CENTER DR
Practice Address - Street 2:BLDG. 1, SUITE 119
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3020
Practice Address - Country:US
Practice Address - Phone:619-464-3153
Practice Address - Fax:619-464-3429
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG57014207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ56955ZOtherBLUE SHIELD
CA00G570140Medicaid
CA1962574715OtherNPI CORPORATE NUMBER
CAG57014Medicare ID - Type Unspecified
CA00G570140Medicaid