Healthcare Provider Details

I. General information

NPI: 1316220080
Provider Name (Legal Business Name): TYLER D. KROHN, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2011
Last Update Date: 09/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

881 ALMA REAL DR SUITE 316
PACIFIC PALISADES CA
90272-3731
US

IV. Provider business mailing address

881 ALMA REAL DR SUITE 316
PACIFIC PALISADES CA
90272-3731
US

V. Phone/Fax

Practice location:
  • Phone: 310-929-5538
  • Fax: 310-929-5537
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA106309
License Number StateCA

VIII. Authorized Official

Name: TYLER KROHN
Title or Position: OWNER/ PRESIDENT
Credential:
Phone: 310-929-5538