Provider Demographics
NPI:1730683970
Name:BOULTER, TYLER DALLIN (MD)
Entity type:Individual
Prefix:DR
First Name:TYLER
Middle Name:DALLIN
Last Name:BOULTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22009
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97269-2009
Mailing Address - Country:US
Mailing Address - Phone:503-558-7372
Mailing Address - Fax:503-344-5140
Practice Address - Street 1:9135 SW BARNES RD STE 961
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6699
Practice Address - Country:US
Practice Address - Phone:503-292-0848
Practice Address - Fax:503-296-0635
Is Sole Proprietor?:No
Enumeration Date:2018-03-22
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH22178207W00000X
390200000X
ORMD215593207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program