Provider Demographics
NPI:1972908150
Name:WITZEL, TYLER (DO)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:WITZEL
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 1:6355 S BUFFALO DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-2133
Mailing Address - Country:US
Mailing Address - Phone:702-216-3346
Mailing Address - Fax:702-671-6883
Practice Address - Street 1:6710 N DURANGO DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89149-4408
Practice Address - Country:US
Practice Address - Phone:702-216-3346
Practice Address - Fax:702-671-6883
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-30
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP60949403207Q00000X
NV23869207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1972908150Medicaid
NV23869OtherSTATE LICENSE