Healthcare Provider Details

I. General information

NPI: 1518806520
Provider Name (Legal Business Name): TYLER HEATON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2026
Last Update Date: 03/26/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1402 S GRAND BLVD # M260
SAINT LOUIS MO
63104-1004
US

IV. Provider business mailing address

4324 W PINE BLVD UNIT A
SAINT LOUIS MO
63108-2206
US

V. Phone/Fax

Practice location:
  • Phone: 314-617-2919
  • Fax:
Mailing address:
  • Phone: 801-552-8119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: