Provider Demographics
NPI:1679846281
Name:JOHNSON, TYLER ELLIOT (IDC)
Entity type:Individual
Prefix:MR
First Name:TYLER
Middle Name:ELLIOT
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:342 DOVER CT
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-4253
Mailing Address - Country:US
Mailing Address - Phone:415-672-2782
Mailing Address - Fax:
Practice Address - Street 1:342 DOVER CT
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-4253
Practice Address - Country:US
Practice Address - Phone:415-672-2782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-13
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB88294451710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman