Provider Demographics
NPI:1588390421
Name:SCOTT, TYLER RYAN (OD)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:RYAN
Last Name:SCOTT
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 1:1001 W ROSEDALE ST APT 1412
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4895
Mailing Address - Country:US
Mailing Address - Phone:951-852-8138
Mailing Address - Fax:
Practice Address - Street 1:116 E ELLISON ST STE C
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-4286
Practice Address - Country:US
Practice Address - Phone:817-295-9696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-25
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10561T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty