Provider Demographics
NPI:1124344502
Name:TYLER, MICHELLE DIANE (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DIANE
Last Name:TYLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MEDICAL CENTER DR
Mailing Address - Street 2:DHMC DEPARTMENT OF PEDIATRICS
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03756-1000
Mailing Address - Country:US
Mailing Address - Phone:603-653-9663
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:DHMC DEPARTMENT OF PEDIATRICS
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756
Practice Address - Country:US
Practice Address - Phone:603-653-9850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-11
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH16197208000000X, 2080N0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1021949Medicaid
NH3086958Medicaid