Provider Demographics
NPI:1073622692
Name:TISDALE, JAMES N (OD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:N
Last Name:TISDALE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:JAMES
Other - Middle Name:N
Other - Last Name:TISDALE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OPTOMETRIST
Mailing Address - Street 1:114 PROFESSIONAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904-2351
Mailing Address - Country:US
Mailing Address - Phone:361-578-8441
Mailing Address - Fax:
Practice Address - Street 1:114 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-2351
Practice Address - Country:US
Practice Address - Phone:361-578-8441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2309TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX440-56-97OtherAETNA
TX410011742OtherTHE RAILROAD RETIREMENT BOARD'S MEDICARE CARRIER
TX82179QOtherBC/BS
TX410011742OtherTHE RAILROAD RETIREMENT BOARD'S MEDICARE CARRIER
TX440-56-97OtherAETNA