Healthcare Provider Details

I. General information

NPI: 1588407811
Provider Name (Legal Business Name): TYLER KEVIN OAKESON OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2024
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3192 WILLOW CREEK RD
PRESCOTT AZ
86301-6610
US

IV. Provider business mailing address

5959 W UTOPIA RD APT 2064
GLENDALE AZ
85308-7162
US

V. Phone/Fax

Practice location:
  • Phone: 928-445-1234
  • Fax: 928-771-8107
Mailing address:
  • Phone: 801-691-2817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT-002795
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: