Provider Demographics
NPI:1134508286
Name:TILLE, CHARLES (OD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:TILLE
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 1:3501 S TAMIAMI TRL
Mailing Address - Street 2:SUITE 302
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-6109
Mailing Address - Country:US
Mailing Address - Phone:253-970-9300
Mailing Address - Fax:
Practice Address - Street 1:3501 S TAMIAMI TRL
Practice Address - Street 2:SUITE 302
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-6109
Practice Address - Country:US
Practice Address - Phone:253-970-9300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-21
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 5235152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist