Provider Demographics
NPI:1972290385
Name:MORTELLARO, TYLER J (DO)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:J
Last Name:MORTELLARO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 LIVE OAK RD
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104-8548
Mailing Address - Country:US
Mailing Address - Phone:732-814-6506
Mailing Address - Fax:
Practice Address - Street 1:1900 23RD ST
Practice Address - Street 2:
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44223-1404
Practice Address - Country:US
Practice Address - Phone:330-971-7225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program