Individual
THADDEUS REX TOLLESON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
619 S FLEISHEL AVE, SUITE 101, TYLER, TX 75701-2004
(903) 595-5514
Mailing address
619 S FLEISHEL AVE, SUITE 101, TYLER, TX 75701-2004
(903) 595-5514
Taxonomy
Speciality
Code
Description
License number
State
207RC0000X
Cardiovascular Disease Physician
J6770
TX
207RI0011X
Interventional Cardiology Physician
Primary
J6770
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
154221901
—
TX
01
—
221985502
UNITED HEALTHCARE
TX
01
—
7773430
AETNA
TX
01
—
8G7380
BCBS
TX
01
—
8V5491
BCBS TRINITY
TX
Enumeration date
09/15/2005
Last updated
04/26/2017
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