Provider Demographics
NPI:1720071012
Name:TYTKO, JAMES M (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:M
Last Name:TYTKO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2145 N FAIRFIELD RD STE 100
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-2783
Mailing Address - Country:US
Mailing Address - Phone:937-558-3900
Mailing Address - Fax:937-558-3999
Practice Address - Street 1:2145 N FAIRFIELD RD STE 100
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-2783
Practice Address - Country:US
Practice Address - Phone:937-558-3900
Practice Address - Fax:937-558-3999
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35046245207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH080152126OtherMEDICARE RR
OH0511986Medicaid
OH0499695Medicare PIN
OHTY0499699Medicare PIN
OH0511986Medicaid
OHA80109Medicare UPIN