Provider Demographics
NPI:1669564407
Name:TYNAN, WILLIAM D (PHD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:D
Last Name:TYNAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-444-9075
Mailing Address - Fax:302-444-9200
Practice Address - Street 1:A.I. DUPONT HOSPITAL FOR CHILDREN
Practice Address - Street 2:1600 ROCKLAND ROAD
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-3607
Practice Address - Country:US
Practice Address - Phone:302-651-4000
Practice Address - Fax:302-651-4945
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEB10000589103TC2200X, 2080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001705190Medicaid
NJ83366608Medicaid
MD6023215Medicaid
PA001705190Medicaid
R22736Medicare UPIN