Provider Demographics
NPI:1942690490
Name:SMITH, TYLER
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 HIGHWAY 49 S
Mailing Address - Street 2:SUITE 2
Mailing Address - City:RICHLAND
Mailing Address - State:MS
Mailing Address - Zip Code:39218-9425
Mailing Address - Country:US
Mailing Address - Phone:769-233-8844
Mailing Address - Fax:769-251-1825
Practice Address - Street 1:1201 HIGHWAY 49 S
Practice Address - Street 2:SUITE 2
Practice Address - City:RICHLAND
Practice Address - State:MS
Practice Address - Zip Code:39218-9425
Practice Address - Country:US
Practice Address - Phone:769-233-8844
Practice Address - Fax:769-251-1825
Is Sole Proprietor?:No
Enumeration Date:2015-02-04
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT2992174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist