Provider Demographics
NPI:1366541849
Name:DORSEY-TYLER, KEVIN RICHARD (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:RICHARD
Last Name:DORSEY-TYLER
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 GOVERNORS LN
Mailing Address - Street 2:SUITE A
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-1988
Mailing Address - Country:US
Mailing Address - Phone:530-891-4523
Mailing Address - Fax:530-891-5934
Practice Address - Street 1:2 GOVERNORS LN
Practice Address - Street 2:SUITE A
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-1988
Practice Address - Country:US
Practice Address - Phone:530-891-4523
Practice Address - Fax:530-891-5934
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2011-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC50630208600000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C506300Medicaid
G17885Medicare UPIN
CA00C506300Medicaid