1154737799 NPI number — TYLER M DUNCAN DO

Table of content: TYLER M DUNCAN DO (NPI 1154737799)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154737799 NPI number — TYLER M DUNCAN DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DUNCAN
Provider First Name:
TYLER
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154737799
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2410 SUSANNAH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNSON CITY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37601-1748
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-282-9011
Provider Business Mailing Address Fax Number:
423-282-0035

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
340 STEELES RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRISTOL
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-280-9011
Provider Business Practice Location Address Fax Number:
423-282-0035
Provider Enumeration Date:
07/03/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  3618 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3618 . This is a "TN MEDICAL LICENSE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".