Basic Information
| Provider Information | |||||||||
| NPI: | 1679673222 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TYLER | ||||||||
| FirstName: | LAMONT | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 645 E STATE HIGHWAY 121 STE 600 | ||||||||
| Address2: | |||||||||
| City: | COPPELL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750197942 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727457500 | ||||||||
| FaxNumber: | 9727454336 | ||||||||
| Practice Location | |||||||||
| Address1: | 10652 S EASTERN AVE | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024762040 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2006 | ||||||||
| LastUpdateDate: | 05/15/2018 | ||||||||
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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 | 207Q00000X | DO2360 | NV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036076076 | 05 | IL | MEDICAID |