Provider Demographics
NPI:1457977928
Name:STATHIS, TYLER JUSTIN (OD)
Entity type:Individual
Prefix:DR
First Name:TYLER
Middle Name:JUSTIN
Last Name:STATHIS
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 1:8612 E SAN FELIPE DR
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-2550
Mailing Address - Country:US
Mailing Address - Phone:480-329-7923
Mailing Address - Fax:
Practice Address - Street 1:15681 N HAYDEN RD STE 115
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-1959
Practice Address - Country:US
Practice Address - Phone:480-948-1131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-22
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ002431152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist