Provider Demographics
NPI:1073028213
Name:FELTON, TY WILLIAM (OD)
Entity Type:Individual
Prefix:
First Name:TY
Middle Name:WILLIAM
Last Name:FELTON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2230 N RESERVE ST STE 330
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-1364
Mailing Address - Country:US
Mailing Address - Phone:406-309-6633
Mailing Address - Fax:406-309-6644
Practice Address - Street 1:2230 N RESERVE ST STE 330
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1364
Practice Address - Country:US
Practice Address - Phone:406-309-6633
Practice Address - Fax:406-309-6644
Is Sole Proprietor?:No
Enumeration Date:2017-12-11
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT3090152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist