Provider Demographics
NPI:1568725893
Name:JOLLEY, TYLER VIRGIL (DPM)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:VIRGIL
Last Name:JOLLEY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2401 S 31ST ST
Mailing Address - Street 2:OFFICE OF PODIATRY
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76508-0001
Mailing Address - Country:US
Mailing Address - Phone:435-749-3903
Mailing Address - Fax:
Practice Address - Street 1:2401 S 31ST ST
Practice Address - Street 2:OFFICE OF PODIATRY
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76508-0001
Practice Address - Country:US
Practice Address - Phone:435-749-3903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-21
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT44-2012213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXT44-2012OtherTEXAS STATE BOARD OF PODIATRIC MEDICAL EXAMINERS