Healthcare Provider Details

I. General information

NPI: 1255994588
Provider Name (Legal Business Name): MR. ETHAN TYLER DUNGAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2019
Last Update Date: 06/29/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 6TH AVE S
BIRMINGHAM AL
35233-1932
US

IV. Provider business mailing address

918 CAHABA RIVER PARC
BIRMINGHAM AL
35243-3264
US

V. Phone/Fax

Practice location:
  • Phone: 205-996-5111
  • Fax:
Mailing address:
  • Phone: 334-467-0124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number1-149801
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number1-149801
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: