MEDICARE: DR. JAMES N. TISDALE O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2309TG	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	410011742	OTHER	TX	THE RAILROAD RETIREMENT BOARD'S MEDICARE CARRIER

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	440-56-97	OTHER	TX	AETNA
3	82179Q	OTHER	TX	BC/BS

General Provider Information

NPI Number	:	1073622692
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMES N. TISDALE O.D.

Provider Business Mailing Address
First Line	:	114 PROFESSIONAL PARK DR
Second Line	:
City	:	VICTORIA
State	:	TX
Zip	:	77904-2351
Country	:	US
Telephone Number	:	361-578-8441
Fax Number	:

Provider Business Practice Location Address
First Line	:	114 PROFESSIONAL PARK DR
Second Line	:
City	:	VICTORIA
State	:	TX
Zip	:	77904-2351
Country	:	US
Telephone Number	:	361-578-8441
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	12/04/2013

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