Healthcare Provider Details

I. General information

NPI: 1992455885
Provider Name (Legal Business Name): TYLER G FULLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2022
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1037 MAIN ST
PEEKSKILL NY
10566-2913
US

IV. Provider business mailing address

1037 MAIN ST
PEEKSKILL NY
10566-2913
US

V. Phone/Fax

Practice location:
  • Phone: 914-734-8800
  • Fax:
Mailing address:
  • Phone: 914-734-8800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number338045
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: