Provider Demographics
NPI:1932636149
Name:DETTRO, TYLER SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:SCOTT
Last Name:DETTRO
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 1:401 W GREENLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-2819
Mailing Address - Country:US
Mailing Address - Phone:517-975-6000
Mailing Address - Fax:
Practice Address - Street 1:401 W GREENLAWN AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-2819
Practice Address - Country:US
Practice Address - Phone:517-975-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-18
Last Update Date:2020-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301501004207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine