Provider Demographics
NPI:1235880493
Name:PRAVONGVIENGKHAM, TYLOR (OD)
Entity Type:Individual
Prefix:DR
First Name:TYLOR
Middle Name:
Last Name:PRAVONGVIENGKHAM
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 1:3303 E BASELINE RD STE 104
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2739
Mailing Address - Country:US
Mailing Address - Phone:480-632-2020
Mailing Address - Fax:
Practice Address - Street 1:3303 E BASELINE RD STE 104
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2739
Practice Address - Country:US
Practice Address - Phone:480-632-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-10
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOPT-002670152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist