Provider Demographics
NPI:1083627830
Name:TALLIS, JAY E (OD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:E
Last Name:TALLIS
Suffix:
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 1:915 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3043
Mailing Address - Country:US
Mailing Address - Phone:309-827-8434
Mailing Address - Fax:309-828-6741
Practice Address - Street 1:915 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3043
Practice Address - Country:US
Practice Address - Phone:309-827-8434
Practice Address - Fax:309-828-6741
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2014-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-007271152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046007271Medicaid
IL046007271Medicaid