Basic Information
| Provider Information | |||||||||
| NPI: | 1629064019 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TYLER | ||||||||
| FirstName: | HAROLD | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 620 E COLLEGE ST | ||||||||
| Address2: | |||||||||
| City: | HOMER | ||||||||
| State: | LA | ||||||||
| PostalCode: | 710403202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3189272024 | ||||||||
| FaxNumber: | 3189273723 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 E COLLEGE ST | ||||||||
| Address2: | |||||||||
| City: | HOMER | ||||||||
| State: | LA | ||||||||
| PostalCode: | 710403202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3189272024 | ||||||||
| FaxNumber: | 3189273723 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 06/28/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 016382 | LA | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1358266 | 05 | LA | MEDICAID |