Provider Demographics
NPI:1790862019
Name:TYNER, MICHAEL E (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
Last Name:TYNER
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 1:1619 ROSELAND DR
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209-3953
Mailing Address - Country:US
Mailing Address - Phone:205-871-8668
Mailing Address - Fax:205-870-3009
Practice Address - Street 1:704 BROOKWOOD VLG
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35209-4549
Practice Address - Country:US
Practice Address - Phone:205-879-2512
Practice Address - Fax:205-870-3009
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-598-TA-717152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL58238Medicare ID - Type UnspecifiedPROV ID
ALT69093Medicare UPIN