Provider Demographics
NPI:1013189877
Name:STALEY, TYLER JAY (MD)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:JAY
Last Name:STALEY
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 9671
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32120-9671
Mailing Address - Country:US
Mailing Address - Phone:386-676-7130
Mailing Address - Fax:386-676-7125
Practice Address - Street 1:350 N CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2733
Practice Address - Country:US
Practice Address - Phone:386-238-3290
Practice Address - Fax:386-238-3278
Is Sole Proprietor?:No
Enumeration Date:2008-04-01
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY44335208100000X
FL1121392081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1013189877OtherTRICARE
FL007276600Medicaid
FL14MV1OtherBCBS
FLGV273ZMedicare PIN