Provider Demographics
NPI:1477642973
Name:PHILPOTT, TYLER (OD)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:
Last Name:PHILPOTT
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 1:5 SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:CT
Mailing Address - Zip Code:06801-1854
Mailing Address - Country:US
Mailing Address - Phone:203-798-2020
Mailing Address - Fax:203-798-2179
Practice Address - Street 1:5 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:CT
Practice Address - Zip Code:06801-1854
Practice Address - Country:US
Practice Address - Phone:203-798-2020
Practice Address - Fax:203-798-2179
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1011152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004067666Medicaid
CT004067666Medicaid
CT410000350Medicare ID - Type Unspecified