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General NPI Number Information
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NPI Number | 1457977928
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Entity Type | Individual
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Provider Name | TYLER JUSTIN STATHIS OD
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Gender | Male
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Dates
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Enumeration Date | 06/22/2020
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Last Update Date | 09/27/2021
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Provider Practice Location Address
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Address Line | 15681 N HAYDEN RD STE 115
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City | SCOTTSDALE
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State | AZ
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Zip | 85260-1959
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Country | US
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Telephone | 480-948-1131
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Fax |
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Provider Business Mailing Address
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Address Line | 8612 E SAN FELIPE DR
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City | SCOTTSDALE
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State | AZ
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Zip | 85258-2550
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Country | US
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Telephone | 480-329-7923
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 002431
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License Number State | AZ
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