Provider Demographics
NPI:1710347224
Name:MACIAS, TYLER
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:MACIAS
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 1:3843 MOLLER RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-2930
Mailing Address - Country:US
Mailing Address - Phone:317-291-3376
Mailing Address - Fax:317-291-3746
Practice Address - Street 1:3843 MOLLER RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-2930
Practice Address - Country:US
Practice Address - Phone:317-291-3376
Practice Address - Fax:317-291-3746
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-25
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN17001419A237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist