Provider Demographics
NPI:1699795872
Name:TYLER, JOHN D
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:D
Last Name:TYLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 S COLUMBIA RD
Mailing Address - Street 2:STE 202
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-5895
Mailing Address - Country:US
Mailing Address - Phone:701-772-1588
Mailing Address - Fax:
Practice Address - Street 1:2100 S COLUMBIA RD
Practice Address - Street 2:STE 202
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-5895
Practice Address - Country:US
Practice Address - Phone:701-772-1588
Practice Address - Fax:701-746-6077
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND37103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
A006OtherTRICARE
TX0005663645OtherAETNA
MN974701009768OtherPREFERRED ONE
NDTYL5227OtherND BLUE CROSS
MN2H520TYOtherMN BLUE CROSS
ND16979Medicaid
ND5227Medicare ID - Type Unspecified