Provider Demographics
NPI:1225247877
Name:PROUTY, TYLER J (MD)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:J
Last Name:PROUTY
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 1:527 MEDICAL PARK DR STE 204
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-9009
Mailing Address - Country:US
Mailing Address - Phone:304-933-3800
Mailing Address - Fax:304-933-3815
Practice Address - Street 1:527 MEDICAL PARK DR STE 205
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9009
Practice Address - Country:US
Practice Address - Phone:304-933-3800
Practice Address - Fax:304-933-3815
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22435207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810009618Medicaid
WV22435OtherWV LICENSE
WV4211642OtherMEDICARE PTAN