Provider Demographics
NPI:1326568270
Name:VAN DE VOORT, TYLER J (MD)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:J
Last Name:VAN DE VOORT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:TYLER
Other - Middle Name:J
Other - Last Name:VANDEVOORT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:835 S VAN BUREN ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-3575
Mailing Address - Country:US
Mailing Address - Phone:920-433-0111
Mailing Address - Fax:
Practice Address - Street 1:835 S VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3526
Practice Address - Country:US
Practice Address - Phone:920-433-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-21
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI81984-20208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100250432Medicaid
WI81984-20OtherWISCONSIN MEDICAL LICENSE