Provider Demographics
NPI:1063474005
Name:TYLER, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
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 786
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52406-0786
Mailing Address - Country:US
Mailing Address - Phone:319-369-4505
Mailing Address - Fax:319-369-4677
Practice Address - Street 1:2815 EDGEWOOD RD SW
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52404-3258
Practice Address - Country:US
Practice Address - Phone:319-396-9097
Practice Address - Fax:319-396-8284
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA17884207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA5075283Medicaid
IAI5585Medicare PIN
IAA00918Medicare UPIN