Provider Demographics
NPI:1922141076
Name:BUNYON, LAMONT TYLER (OD)
Entity Type:Individual
Prefix:DR
First Name:LAMONT
Middle Name:TYLER
Last Name:BUNYON
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 1:3731 BRANCH AVE
Mailing Address - Street 2:SUITE #211
Mailing Address - City:TEMPLE HILLS
Mailing Address - State:MD
Mailing Address - Zip Code:20748-1404
Mailing Address - Country:US
Mailing Address - Phone:301-702-0090
Mailing Address - Fax:301-702-0023
Practice Address - Street 1:3731 BRANCH AVE
Practice Address - Street 2:SUITE #211
Practice Address - City:TEMPLE HILLS
Practice Address - State:MD
Practice Address - Zip Code:20748-1404
Practice Address - Country:US
Practice Address - Phone:301-702-0090
Practice Address - Fax:301-702-0023
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1617152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDTA1617OtherSTATE LICENSE