Basic Information
| Provider Information | |||||||||
| NPI: | 1447612478 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | TYLER | ||||||||
| MiddleName: | JOHN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 856 J CLYDE MORRIS BLVD STE A | ||||||||
| Address2: | |||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236011318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573165800 | ||||||||
| FaxNumber: | 7575345190 | ||||||||
| Practice Location | |||||||||
| Address1: | 7590 HOSPITAL DR BLDG C204 | ||||||||
| Address2: | |||||||||
| City: | GLOUCESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 230614178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8046935560 | ||||||||
| FaxNumber: | 8046930457 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2016 | ||||||||
| LastUpdateDate: | 06/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | R4000 | KY | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 0101268521 | VA | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.