Provider Demographics
NPI:1225851819
Name:MANGOLD, TYLER RAY (OD)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:RAY
Last Name:MANGOLD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:TYLER
Other - Middle Name:RAY
Other - Last Name:MANGOLD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:360 BRIDLE LN S
Mailing Address - Street 2:
Mailing Address - City:WEST CARROLLTON
Mailing Address - State:OH
Mailing Address - Zip Code:45449-2118
Mailing Address - Country:US
Mailing Address - Phone:513-465-3613
Mailing Address - Fax:
Practice Address - Street 1:1020 WOODMAN DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45432-1446
Practice Address - Country:US
Practice Address - Phone:937-258-4570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program