Provider Demographics
NPI:1184147142
Name:TYSON, MICHAEL TODD X
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:TODD
Last Name:TYSON
Suffix:X
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:696 WOODBINE AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14619-2030
Mailing Address - Country:US
Mailing Address - Phone:585-532-0636
Mailing Address - Fax:
Practice Address - Street 1:696 WOODBINE AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14619-2030
Practice Address - Country:US
Practice Address - Phone:585-532-0636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY760970342172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty