Healthcare Provider Details

I. General information

NPI: 1124223581
Provider Name (Legal Business Name): TYLER CHARLES ENSLEY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2007
Last Update Date: 12/11/2019
Certification Date: 12/11/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CAPE CORAL HOSPITAL 636 DEL PRADO BLVD
CAPE CORAL FL
33990
US

IV. Provider business mailing address

PO BOX 151368 CAPE CORAL EMERGENCY PHYSICIANS, LLC
CAPE CORAL FL
33915
US

V. Phone/Fax

Practice location:
  • Phone: 239-424-3513
  • Fax: 239-424-4039
Mailing address:
  • Phone: 239-424-3513
  • Fax: 239-424-4039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberOS15967
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: