Provider Demographics
NPI:1679957427
Name:LYSTRUP, ROBERT (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:LYSTRUP
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 1:5055 E BROADWAY BLVD STE A100
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-3629
Mailing Address - Country:US
Mailing Address - Phone:520-327-0460
Mailing Address - Fax:
Practice Address - Street 1:2260 N ROSEMONT BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2137
Practice Address - Country:US
Practice Address - Phone:520-318-1033
Practice Address - Fax:520-318-1338
Is Sole Proprietor?:No
Enumeration Date:2015-07-10
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVLL2644207Q00000X
AZ58675207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine