Provider Demographics
NPI:1922461235
Name:MENGE, TYLER DRAKE (MD)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:DRAKE
Last Name:MENGE
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:PO BOX 230457
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97281-0457
Mailing Address - Country:US
Mailing Address - Phone:503-906-7300
Mailing Address - Fax:
Practice Address - Street 1:3131 S STATE ST STE 309
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-1658
Practice Address - Country:US
Practice Address - Phone:503-906-7300
Practice Address - Fax:503-245-8219
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-04
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.139934207N00000X
MI4301501739207N00000X, 207ZD0900X
ORMD203405207ZD0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Single Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatology