Provider Demographics
NPI:1053678284
Name:MITTELSTAEDT, TYLER SCOTT (MD-MPH)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:SCOTT
Last Name:MITTELSTAEDT
Suffix:
Gender:M
Credentials:MD-MPH
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 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:
Practice Address - Street 1:1510 DIVISION ST STE 210
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1599
Practice Address - Country:US
Practice Address - Phone:503-723-6525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-12
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD183147208600000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery