Healthcare Provider Details

I. General information

NPI: 1841559549
Provider Name (Legal Business Name): TYLER MARIE KAMENETSKIY D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TYLER MARIE ESTEP

II. Dates (important events)

Enumeration Date: 05/15/2012
Last Update Date: 05/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13123 E 16TH AVE
AURORA CO
80045-7106
US

IV. Provider business mailing address

8930 EDGEFIELD DR
COLORADO SPRINGS CO
80920-7204
US

V. Phone/Fax

Practice location:
  • Phone: 720-848-1234
  • Fax:
Mailing address:
  • Phone: 719-453-5621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number55413
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5357
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: