Individual
DR. MARTIN S. TYSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
1155 W PARKVIEW ST, SUITE 1G, BOLIVAR, MO 65613-8279
(417) 326-8700
(417) 328-6755
Mailing address
1500 N OAKLAND AVE, BOLIVAR, MO 65613-3011
(417) 326-6000
(417) 328-6338
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
2001010358
MO
2086S0127X
Trauma Surgery Physician
2001010358
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
020049033
RAILROAD MEDICARE
MO
05
—
245315106
—
MO
01
—
431560263006
TRICARE
MO
Enumeration date
11/30/2006
Last updated
12/10/2015
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