MEDICARE: DAVID W TYBOR OD PC

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	3233TG	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00E28C	OTHER	TX	BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255303442
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAVID W TYBOR OD PC

Provider Business Mailing Address
First Line	:	6000 W WM CANNON
Second Line	:	BLDG A STE 100
City	:	AUSTIN
State	:	TX
Zip	:	78749
Country	:	US
Telephone Number	:	512-288-0444
Fax Number	:	512-288-1009

Provider Business Practice Location Address
First Line	:	6000 W WILLIAM CANNON DR
Second Line	:	BLDG A STE 100
City	:	AUSTIN
State	:	TX
Zip	:	78749-1975
Country	:	US
Telephone Number	:	512-288-0444
Fax Number	:	512-288-1009

Authorized Official
Title or Position	:	OFFICE ASSISTANT
Name	:	MISS TAMARA R HARPER
Credential	:
Telephone Number	:	512-288-0444

Provider Enumeration Date	:	02/02/2006
Last Update Date	:	05/09/2012

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