Basic Information
| Provider Information | |||||||||
| NPI: | 1578149266 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOYACK | ||||||||
| FirstName: | TYLER | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4800 N 22ND ST STE 210 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850164963 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029551000 | ||||||||
| FaxNumber: | 6025084830 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 S 20TH AVE | ||||||||
| Address2: | |||||||||
| City: | SAFFORD | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855463317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284286930 | ||||||||
| FaxNumber: | 6025084830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2021 | ||||||||
| LastUpdateDate: | 08/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT-002496 | AZ | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.