Provider Demographics
NPI:1518490606
Name:DE WITT, TYLER ABRAHAM (MD)
Entity Type:Individual
Prefix:MR
First Name:TYLER
Middle Name:ABRAHAM
Last Name:DE WITT
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 1:401 E CHESTNUT ST UNIT 600
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-5705
Mailing Address - Country:US
Mailing Address - Phone:502-588-4450
Mailing Address - Fax:
Practice Address - Street 1:120 HELMWOOD PLAZA DR STE 103
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-3459
Practice Address - Country:US
Practice Address - Phone:270-979-7171
Practice Address - Fax:270-979-7172
Is Sole Proprietor?:No
Enumeration Date:2017-04-06
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR46912084P0800X
KY390200000X
KY560912084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program