Provider Demographics
NPI:1588186191
Name:PROVOST, TYLER J (DO)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:J
Last Name:PROVOST
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 1:2508 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:THOMSON
Mailing Address - State:GA
Mailing Address - Zip Code:30824-0040
Mailing Address - Country:US
Mailing Address - Phone:706-595-1090
Mailing Address - Fax:706-595-6010
Practice Address - Street 1:2508 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:THOMSON
Practice Address - State:GA
Practice Address - Zip Code:30824-0040
Practice Address - Country:US
Practice Address - Phone:706-595-1090
Practice Address - Fax:706-595-6010
Is Sole Proprietor?:No
Enumeration Date:2017-07-14
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA89610207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine