Provider Demographics
NPI:1760034110
Name:ELLSWORTH, TYLER WILLIAM (OD)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:WILLIAM
Last Name:ELLSWORTH
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 1:8075 MALL PKWY STE 103
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-6993
Mailing Address - Country:US
Mailing Address - Phone:770-484-2955
Mailing Address - Fax:
Practice Address - Street 1:8075 MALL PKWY STE 103
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-6993
Practice Address - Country:US
Practice Address - Phone:770-484-2955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT003180152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty