Provider Demographics
NPI:1447357249
Name:TYLER, DOUGLAS (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:TYLER
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:PO BOX 641115
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064
Mailing Address - Country:US
Mailing Address - Phone:310-828-0733
Mailing Address - Fax:310-828-0711
Practice Address - Street 1:2811 WILSHIRE BLVD
Practice Address - Street 2:#800
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403
Practice Address - Country:US
Practice Address - Phone:310-828-0733
Practice Address - Fax:310-828-0711
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42734207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G427340Medicaid
CA00G427340OtherBLUE SHIELD
A49092Medicare UPIN
CA00G427340Medicaid