Basic Information
| Provider Information | |||||||||
| NPI: | 1689142770 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JEVNE | ||||||||
| FirstName: | TYLER | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 COMMON DR | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799365922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155954375 | ||||||||
| FaxNumber: | 9155954460 | ||||||||
| Practice Location | |||||||||
| Address1: | 6751 N 72ND ST STE 105 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681221746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025722020 | ||||||||
| FaxNumber: | 4025722150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2018 | ||||||||
| LastUpdateDate: | 10/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 9562T | TX | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 152W00000X | 1528 | NE | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.