Provider Demographics
NPI:1073713228
Name:PATTERSON, PHILLIP LANE SR (OD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:LANE
Last Name:PATTERSON
Suffix:SR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1905 N JACKSON ST
Mailing Address - Street 2:STE 440
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-2200
Mailing Address - Country:US
Mailing Address - Phone:931-455-8707
Mailing Address - Fax:931-455-2505
Practice Address - Street 1:1905 N JACKSON ST
Practice Address - Street 2:STE 440
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-2200
Practice Address - Country:US
Practice Address - Phone:931-455-8707
Practice Address - Fax:931-455-2505
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-24
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN601152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNT61292Medicare UPIN