Healthcare Provider Details

I. General information

NPI: 1699668038
Provider Name (Legal Business Name): TYLER THOMAS OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2025
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6035 FAIRVIEW RD
CHARLOTTE NC
28210-3256
US

IV. Provider business mailing address

6035 FAIRVIEW RD
CHARLOTTE NC
28210-3256
US

V. Phone/Fax

Practice location:
  • Phone: 704-295-3000
  • Fax: 704-295-3468
Mailing address:
  • Phone: 704-295-3000
  • Fax: 704-295-3468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2916
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: