Healthcare Provider Details

I. General information

NPI: 1215486121
Provider Name (Legal Business Name): TYLER REPPERT O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2016
Last Update Date: 03/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 WILLOW STREET PIKE N STE 310
WILLOW STREET PA
17584-9386
US

IV. Provider business mailing address

2600 WILLOW STREET PIKE N STE 310
WILLOW STREET PA
17584-9386
US

V. Phone/Fax

Practice location:
  • Phone: 717-947-4843
  • Fax: 717-947-4279
Mailing address:
  • Phone: 717-947-4843
  • Fax: 717-947-4279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG003207
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: