Healthcare Provider Details

I. General information

NPI: 1578798757
Provider Name (Legal Business Name): TYLER GUTHRIE JOHNSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2009
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 RANDALLIA DR
FORT WAYNE IN
46805-4638
US

IV. Provider business mailing address

608 UNION CHAPEL RD
FORT WAYNE IN
46845-9357
US

V. Phone/Fax

Practice location:
  • Phone: 260-373-4000
  • Fax: 260-482-4442
Mailing address:
  • Phone: 260-482-4440
  • Fax: 260-482-4442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number5101018131
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5101018131
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number02003913A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: