Provider Demographics
NPI:1942668389
Name:ROSE, TYLER S (OD)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:S
Last Name:ROSE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 208177
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-8177
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0766
Practice Address - Street 1:330 W LAKE LANSING RD
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-8527
Practice Address - Country:US
Practice Address - Phone:517-337-8182
Practice Address - Fax:517-332-0038
Is Sole Proprietor?:No
Enumeration Date:2016-01-30
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV905152W00000X
MI4901005104152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist