Provider Demographics
NPI:1255994588
Name:DUNGAN, ETHAN TYLER
Entity type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:TYLER
Last Name:DUNGAN
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 1:918 CAHABA RIVER PARC
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35243-3264
Mailing Address - Country:US
Mailing Address - Phone:334-467-0124
Mailing Address - Fax:
Practice Address - Street 1:1802 6TH AVE S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-1932
Practice Address - Country:US
Practice Address - Phone:205-996-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-22
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-149801207RI0200X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease