Provider Demographics
NPI:1760265912
Name:MINNICH, TYLER JOEL (OD)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:JOEL
Last Name:MINNICH
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 1:17W726 BUTTERFIELD RD APT 208
Mailing Address - Street 2:
Mailing Address - City:OAKBROOK TERRACE
Mailing Address - State:IL
Mailing Address - Zip Code:60181-4228
Mailing Address - Country:US
Mailing Address - Phone:574-238-6061
Mailing Address - Fax:
Practice Address - Street 1:7610 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130-2295
Practice Address - Country:US
Practice Address - Phone:708-366-9278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.011753152W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology