Healthcare Provider Details

I. General information

NPI: 1346273901
Provider Name (Legal Business Name): TILLMAN EYECARE EAST P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 03/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 S GREEN RIVER RD
EVANSVILLE IN
47715-5744
US

IV. Provider business mailing address

1700 S GREEN RIVER RD
EVANSVILLE IN
47715-5744
US

V. Phone/Fax

Practice location:
  • Phone: 812-476-4936
  • Fax: 812-962-4300
Mailing address:
  • Phone: 812-476-4936
  • Fax: 812-962-4300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18002713B
License Number StateIN

VIII. Authorized Official

Name: CRYSTAL D VANDIVER
Title or Position: OFFICE MANAGER
Credential:
Phone: 812-476-4936