Provider Demographics
NPI:1124211990
Name:TICKNER, PHILLIP BRYAN (OD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:BRYAN
Last Name:TICKNER
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 1:109 ANDERSON CIR
Mailing Address - Street 2:
Mailing Address - City:TRUSSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35173-1001
Mailing Address - Country:US
Mailing Address - Phone:205-919-0671
Mailing Address - Fax:
Practice Address - Street 1:8551 WHITFIELD AVE
Practice Address - Street 2:
Practice Address - City:LEEDS
Practice Address - State:AL
Practice Address - Zip Code:35094-7560
Practice Address - Country:US
Practice Address - Phone:205-655-0719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-23
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-B65-TA-769152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist