Provider Demographics
NPI:1679673222
Name:TYLER, LAMONT (DO)
Entity Type:Individual
Prefix:
First Name:LAMONT
Middle Name:
Last Name:TYLER
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 1:645 E STATE HIGHWAY 121 STE 600
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-7942
Mailing Address - Country:US
Mailing Address - Phone:972-745-7500
Mailing Address - Fax:972-745-4336
Practice Address - Street 1:10652 S EASTERN AVE
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052
Practice Address - Country:US
Practice Address - Phone:702-476-2040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVDO2360207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036076076Medicaid
ILCA2264Medicare ID - Type UnspecifiedRR GROUP #
ILK04868Medicare ID - Type UnspecifiedINDIVIDUAL #
D16790Medicare UPIN
IL833120Medicare ID - Type UnspecifiedGROUP #