Individual provider · NPI-1

Dr. Tyler William Ellsworth, OD

Optometrist · Lithonia, GA

NPI number1760034110
StatusActive
Last updated in NPPESJul 15, 2019

Details

NPI
1760034110
Entity type
Individual (NPI-1)
Name
Dr. Tyler William Ellsworth
Credential
OD
Sex
Male
Sole proprietor
Yes
Enumeration date
Jul 15, 2019
Last updated
Jul 15, 2019

Taxonomy and licenses

Taxonomy codeDescriptionLicenseStatePrimary
152W00000X OptometristOPT003180GAYes

Practice location

8075 Mall Pkwy Ste 103
Lithonia, GA 30038-6993

Phone 770-484-2955

Mailing address

8075 Mall Pkwy Ste 103
Lithonia, GA 30038-6993

Phone 770-484-2955

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