Provider Demographics
NPI:1689142770
Name:JEVNE, TYLER R (OD)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:R
Last Name:JEVNE
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 1:1400 COMMON DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-5922
Mailing Address - Country:US
Mailing Address - Phone:915-595-4375
Mailing Address - Fax:915-595-4460
Practice Address - Street 1:6751 N 72ND ST STE 105
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68122-1746
Practice Address - Country:US
Practice Address - Phone:402-572-2020
Practice Address - Fax:402-572-2150
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-06
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9562T152W00000X
NE1528152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty