Healthcare Provider Details

I. General information

NPI: 1275630626
Provider Name (Legal Business Name): CHARLES P TILLMAN JR. O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 05/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3126 E ROANE AVE
EUPORA MS
39744-2638
US

IV. Provider business mailing address

PO BOX 225 3126 E ROANE AVE
EUPORA MS
39744-0225
US

V. Phone/Fax

Practice location:
  • Phone: 662-258-2020
  • Fax: 662-258-2030
Mailing address:
  • Phone: 662-258-2020
  • Fax: 662-258-2030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number519
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: