Provider Demographics
NPI:1073962163
Name:ELSON, ALEXANDER TYLER (OD)
Entity Type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:TYLER
Last Name:ELSON
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 1:39 TAROCCO
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-0304
Mailing Address - Country:US
Mailing Address - Phone:949-338-7027
Mailing Address - Fax:
Practice Address - Street 1:17300 17TH ST
Practice Address - Street 2:#M
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-1955
Practice Address - Country:US
Practice Address - Phone:714-838-9664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-09
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33390152W00000X, 152WC0802X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics