Provider Demographics
NPI:1316574387
Name:GRAVES, TYLER (DO)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:GRAVES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 CAMBRIDGE AVE W
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646-2003
Mailing Address - Country:US
Mailing Address - Phone:850-591-8180
Mailing Address - Fax:
Practice Address - Street 1:5001 HARDY ST
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1308
Practice Address - Country:US
Practice Address - Phone:601-296-3963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-26
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IDO-1887207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program