Provider Demographics
NPI:1760692115
Name:LEETE, TYLER (MD)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:
Last Name:LEETE
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 1:914 MUSTANG RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MURPHY
Mailing Address - State:TX
Mailing Address - Zip Code:75094-4474
Mailing Address - Country:US
Mailing Address - Phone:972-633-9735
Mailing Address - Fax:
Practice Address - Street 1:910 E HOUSTON ST STE 650
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8370
Practice Address - Country:US
Practice Address - Phone:903-606-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10022133390200000X
TXN21702085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX284950704Medicaid
TX284950705Medicaid
TXP02587391OtherMCRR
TXP02593035OtherMCRR