Healthcare Provider Details

I. General information

NPI: 1386123750
Provider Name (Legal Business Name): TYLER DYLAN BUZZARD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2018
Last Update Date: 08/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 E EXCELSIOR AVE
VINITA OK
74301-4226
US

IV. Provider business mailing address

405 E EXCELSIOR AVE
VINITA OK
74301-4226
US

V. Phone/Fax

Practice location:
  • Phone: 918-256-6476
  • Fax:
Mailing address:
  • Phone: 918-256-6476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: