Provider Demographics
NPI:1417365123
Name:DOERSAM, TYLER (OD)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:
Last Name:DOERSAM
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 1:20505 RAND RD
Mailing Address - Street 2:STE 500
Mailing Address - City:KILDEER
Mailing Address - State:IL
Mailing Address - Zip Code:60047-3004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:118 LAKESIDE DR
Practice Address - Street 2:APT 434
Practice Address - City:SAINT CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-7905
Practice Address - Country:US
Practice Address - Phone:815-821-3088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-25
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010839152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist