Healthcare Provider Details

I. General information

NPI: 1851611842
Provider Name (Legal Business Name): MATTHEW DAVID TYLER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2010
Last Update Date: 07/17/2023
Certification Date: 05/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 MARKET PTE DR STE 100
BLOOMINGTON MN
55435-5435
US

IV. Provider business mailing address

4300 MARKET PTE DR STE 100
BLOOMINGTON MN
55435-5435
US

V. Phone/Fax

Practice location:
  • Phone: 952-767-4574
  • Fax:
Mailing address:
  • Phone: 952-767-4574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number006096
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number73714
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: