Provider Demographics
NPI:1932172418
Name:TYLER, BRADFORD ALAN (MD)
Entity Type:Individual
Prefix:
First Name:BRADFORD
Middle Name:ALAN
Last Name:TYLER
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 1:1202 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7307
Mailing Address - Country:US
Mailing Address - Phone:910-341-3300
Mailing Address - Fax:910-815-2882
Practice Address - Street 1:1202 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7307
Practice Address - Country:US
Practice Address - Phone:910-341-3300
Practice Address - Fax:910-815-2882
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22507208600000X
NC9701885208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT67488Medicaid
SCGP4697Medicaid
SCG98432Medicare UPIN
SCT67488Medicaid
SCGP4697Medicaid