Provider Demographics
NPI:1144429317
Name:NEITLICH, TYLER M (MD)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:M
Last Name:NEITLICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17310 WRIGHT ST STE 103
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130-2405
Mailing Address - Country:US
Mailing Address - Phone:833-228-6889
Mailing Address - Fax:877-853-0376
Practice Address - Street 1:1 BURDICK EXPY W
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-4406
Practice Address - Country:US
Practice Address - Phone:701-857-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND161482085R0202X
WY12500C2085R0202X
FLME994872085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME99487OtherMEDICAL LICENSE