Healthcare Provider Details

I. General information

NPI: 1144646209
Provider Name (Legal Business Name): TYLER J. ELAM D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2014
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 INTERSTATE DR
GRAYSON KY
41143-1704
US

IV. Provider business mailing address

PO BOX 936
LONDON KY
40743-0936
US

V. Phone/Fax

Practice location:
  • Phone: 606-474-0669
  • Fax: 606-474-0376
Mailing address:
  • Phone: 606-330-7835
  • Fax: 859-744-1177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number04118
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: