Provider Demographics
NPI:1295230118
Name:TEWILLIAGER, TYLER (DPM)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:TEWILLIAGER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 DUTCHMANS PKWY STE 215
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-3343
Mailing Address - Country:US
Mailing Address - Phone:502-721-8288
Mailing Address - Fax:
Practice Address - Street 1:6400 DUTCHMANS PKWY STE 215
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-3343
Practice Address - Country:US
Practice Address - Phone:502-721-8288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-25
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPOD.0000876213E00000X, 213ES0103X
KY282269213E00000X, 213ES0103X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program