Healthcare Provider Details

I. General information

NPI: 1386025336
Provider Name (Legal Business Name): TYLER JORDAN ZACHARY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2015
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1727 IMPERIAL BLVD BLDG 2
LAKE CHARLES LA
70605-5393
US

IV. Provider business mailing address

501 DR MICHAEL DEBAKEY DR
LAKE CHARLES LA
70601-5724
US

V. Phone/Fax

Practice location:
  • Phone: 337-310-3670
  • Fax: 337-421-1408
Mailing address:
  • Phone: 433-337-8400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number324348
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: