Provider Demographics
NPI:1326007592
Name:TANTUM, LLOYD ALTON (OD)
Entity Type:Individual
Prefix:
First Name:LLOYD
Middle Name:ALTON
Last Name:TANTUM
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 1:702 S FOOTHILLS PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801-2300
Mailing Address - Country:US
Mailing Address - Phone:865-982-6761
Mailing Address - Fax:865-982-7402
Practice Address - Street 1:1732 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37801-5510
Practice Address - Country:US
Practice Address - Phone:865-982-6761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2017-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTOPT-OPT-LIC-823152WC0802X
TNODT694152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNT61175Medicare UPIN
TN3715350Medicare ID - Type Unspecified