Healthcare Provider Details

I. General information

NPI: 1013189877
Provider Name (Legal Business Name): TYLER JAY STALEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2008
Last Update Date: 07/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 N CLYDE MORRIS BLVD
DAYTONA BEACH FL
32114-2733
US

IV. Provider business mailing address

PO BOX 9671
DAYTONA BEACH FL
32120-9671
US

V. Phone/Fax

Practice location:
  • Phone: 386-238-3290
  • Fax: 386-238-3278
Mailing address:
  • Phone: 386-676-7130
  • Fax: 386-676-7125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number44335
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number112139
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: