Basic Information
| Provider Information | |||||||||
| NPI: | 1912227125 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | TYLER | ||||||||
| MiddleName: | BLAIR | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 N MARTEL AVE | ||||||||
| Address2: | |||||||||
| City: | WEST HOLLYWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900466611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234365019 | ||||||||
| FaxNumber: | 3233379142 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 N VERMONT AVE STE 407 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900276086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3236620492 | ||||||||
| FaxNumber: | 3236620196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2010 | ||||||||
| LastUpdateDate: | 07/20/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | R72287 | AZ | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 262216 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 2083P0901X | 262216-1 | NY | N | Allopathic & Osteopathic Physicians | Preventive Medicine | Public Health & General Preventive Medicine | 2083P0901X | A148240 | CA | Y | Allopathic & Osteopathic Physicians | Preventive Medicine | Public Health & General Preventive Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00695941 | 05 | NY | MEDICAID |