Provider Demographics
NPI:1912227125
Name:EVANS, TYLER BLAIR (MD)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:BLAIR
Last Name:EVANS
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 1:1001 N MARTEL AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90046-6611
Mailing Address - Country:US
Mailing Address - Phone:323-436-5019
Mailing Address - Fax:323-337-9142
Practice Address - Street 1:250 QUAIL RIDGE RD
Practice Address - Street 2:
Practice Address - City:SCOTTS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95066-4821
Practice Address - Country:US
Practice Address - Phone:408-341-9606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-10
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR72287207R00000X
NY262216207R00000X
NY262216-12083P0901X
CAA1482402083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00695941Medicaid
NY331947Medicare Oscar/Certification
NY00695941Medicaid
NY331043Medicare Oscar/Certification
NY331944Medicare Oscar/Certification
NY331954Medicare Oscar/Certification
NY331978Medicare Oscar/Certification
NY331945Medicare Oscar/Certification
NYW6L111Medicare Oscar/Certification
NY331952Medicare Oscar/Certification
NY331943Medicare Oscar/Certification
NY331946Medicare Oscar/Certification
NYG100000410Medicare Oscar/Certification
NY331009Medicare Oscar/Certification