Provider Demographics
NPI:1447612478
Name:ANDERSON, TYLER JOHN
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:JOHN
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:856 J CLYDE MORRIS BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:757-316-5800
Mailing Address - Fax:757-534-5190
Practice Address - Street 1:7590 HOSPITAL DR BLDG C204
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061-4178
Practice Address - Country:US
Practice Address - Phone:804-693-5560
Practice Address - Fax:804-693-0457
Is Sole Proprietor?:No
Enumeration Date:2016-03-29
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR4000207W00000X
VA0101268521207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology