Provider Demographics
NPI:1881058303
Name:DOUGLAS TYLER M.D. A PROFESSIONAL
Entity type:Organization
Organization Name:DOUGLAS TYLER M.D. A PROFESSIONAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:TYLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-828-0733
Mailing Address - Street 1:PO BOX 641115
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-6115
Mailing Address - Country:US
Mailing Address - Phone:310-470-0386
Mailing Address - Fax:310-694-0119
Practice Address - Street 1:2811 WILSHIRE BLVD
Practice Address - Street 2:SUITE 800
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-4803
Practice Address - Country:US
Practice Address - Phone:310-828-0733
Practice Address - Fax:310-828-0711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-11
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42734207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA49092Medicare UPIN