Provider Demographics
NPI:1407260094
Name:WYATT, TYLER WAYNE (OD)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:WAYNE
Last Name:WYATT
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 1:127 W 3100 S
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-6521
Mailing Address - Country:US
Mailing Address - Phone:702-513-8201
Mailing Address - Fax:
Practice Address - Street 1:500 FOOTHILL DR
Practice Address - Street 2:OPTOMETRY DEPARTMENT (112)
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84148-0001
Practice Address - Country:US
Practice Address - Phone:801-582-1565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-11
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9050293-9934152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management