Provider Demographics
NPI:1568251288
Name:CARTER, TYLER SHANE (OD)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:SHANE
Last Name:CARTER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1489 JEFFERY RD
Mailing Address - Street 2:
Mailing Address - City:OREGONIA
Mailing Address - State:OH
Mailing Address - Zip Code:45054-9723
Mailing Address - Country:US
Mailing Address - Phone:937-725-9126
Mailing Address - Fax:
Practice Address - Street 1:87 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-8941
Practice Address - Country:US
Practice Address - Phone:937-282-2433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-01
Last Update Date:2025-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH007375152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program