MEDICARE: TYLER RAY MANGOLD OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPT.007441	OH

General Provider Information

NPI Number	:	1225851819
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYLER RAY MANGOLD OD

Provider Business Mailing Address
First Line	:	360 BRIDLE LN S
Second Line	:
City	:	WEST CARROLLTON
State	:	OH
Zip	:	45449-2118
Country	:	US
Telephone Number	:	513-465-3613
Fax Number	:

Provider Business Practice Location Address
First Line	:	5274 SALEM AVE
Second Line	:
City	:	TROTWOOD
State	:	OH
Zip	:	45426-1702
Country	:	US
Telephone Number	:	937-887-3937
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/04/2024
Last Update Date	:	12/26/2025

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