Provider Demographics
NPI:1124607858
Name:GAMMON, TYLER (DO)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:GAMMON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 505673
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5673
Mailing Address - Country:US
Mailing Address - Phone:417-730-6430
Mailing Address - Fax:417-269-7567
Practice Address - Street 1:3801 S NATIONAL AVE STE 1122
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-6090
Practice Address - Country:US
Practice Address - Phone:417-269-7728
Practice Address - Fax:417-269-7729
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-08
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2024024463207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine