Healthcare Provider Details

I. General information

NPI: 1275612798
Provider Name (Legal Business Name): LAFAYETTE MICHAEL TYLEE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15080 7TH ST.
VICTORVILLE CA
92395-3865
US

IV. Provider business mailing address

15797 LIME ST.
HESPERIQ CA
92345-3914
US

V. Phone/Fax

Practice location:
  • Phone: 760-243-7330
  • Fax: 760-243-6990
Mailing address:
  • Phone: 760-948-5768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberG52123
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: