Provider Demographics
NPI:1235880493
Name:PRAVONGVIENGKHAM, TYLOR (OD)
Entity type:Individual
Prefix:DR
First Name:TYLOR
Middle Name:
Last Name:PRAVONGVIENGKHAM
Suffix:
Gender:
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4915 E BASELINE RD STE 115
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2966
Mailing Address - Country:US
Mailing Address - Phone:480-279-4400
Mailing Address - Fax:
Practice Address - Street 1:4915 E BASELINE RD STE 115
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2966
Practice Address - Country:US
Practice Address - Phone:480-279-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-10
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOPT-002670152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist