Provider Demographics
NPI:1538335369
Name:TYLER, MARY ALLISON ROENSCH (MD)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ALLISON ROENSCH
Last Name:TYLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:ALLISON
Other - Last Name:ROENSCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2377 LENORA CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-3232
Mailing Address - Country:US
Mailing Address - Phone:770-979-2020
Mailing Address - Fax:770-978-3321
Practice Address - Street 1:2377 LENORA CHURCH RD
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-3232
Practice Address - Country:US
Practice Address - Phone:770-979-2020
Practice Address - Fax:770-978-3321
Is Sole Proprietor?:No
Enumeration Date:2008-05-01
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10031491207W00000X
GA066312207W00000X
GA66312207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003113439AMedicaid