Provider Demographics
NPI:1063510113
Name:TILLAR, WILLIAM THOMAS III (OD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:THOMAS
Last Name:TILLAR
Suffix:III
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 1:425 S MAIN ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:EMPORIA
Mailing Address - State:VA
Mailing Address - Zip Code:23847-2300
Mailing Address - Country:US
Mailing Address - Phone:434-634-5195
Mailing Address - Fax:434-634-0203
Practice Address - Street 1:425 S MAIN ST
Practice Address - Street 2:SUITE D
Practice Address - City:EMPORIA
Practice Address - State:VA
Practice Address - Zip Code:23847-2300
Practice Address - Country:US
Practice Address - Phone:434-634-5195
Practice Address - Fax:434-634-0203
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000522152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA022075OtherANTHEM BC/BS OF VIRGINIA
VA9201301Medicaid
T21515Medicare UPIN
VA410000369Medicare PIN