Provider Demographics
NPI:1407167620
Name:WILLSON, TYLER JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:JAMES
Last Name:WILLSON
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:PO BOX 3755
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-0755
Mailing Address - Country:US
Mailing Address - Phone:402-354-2100
Mailing Address - Fax:402-354-2155
Practice Address - Street 1:933 E PIERCE ST
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-4626
Practice Address - Country:US
Practice Address - Phone:712-396-4360
Practice Address - Fax:712-396-7069
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2017-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-41201207R00000X, 208M00000X, 208M00000X
NE27294208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1407167620Medicaid
NE10026327300Medicaid
IA1407167620Medicaid
NE10026327300Medicaid