Healthcare Provider Details

I. General information

NPI: 1316206394
Provider Name (Legal Business Name): TYLER C REYNARD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2012
Last Update Date: 05/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 THE CITY DR S
ORANGE CA
92868-3201
US

IV. Provider business mailing address

PO BOX 513266
LOS ANGELES CA
90051-3266
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-7004
  • Fax:
Mailing address:
  • Phone: 714-456-7004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA115762
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: