Provider Demographics
NPI:1194468447
Name:MIKSANEK, TYLER JAMES (MD)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:JAMES
Last Name:MIKSANEK
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 RIDGE AVE STE 1223
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1700
Mailing Address - Country:US
Mailing Address - Phone:847-570-2040
Mailing Address - Fax:
Practice Address - Street 1:303 W LAKE ST STE 200
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101-2500
Practice Address - Country:US
Practice Address - Phone:331-221-9001
Practice Address - Fax:331-221-3971
Is Sole Proprietor?:No
Enumeration Date:2022-04-14
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036173563207Q00000X
IL125.080196207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine