Provider Demographics
NPI:1336124809
Name:TILLMAN, CHARLES O III (PT)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:O
Last Name:TILLMAN
Suffix:III
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5017 E LAKEVIEW RD
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74075-3022
Mailing Address - Country:US
Mailing Address - Phone:405-624-2712
Mailing Address - Fax:
Practice Address - Street 1:1201 HERITAGE CIR
Practice Address - Street 2:
Practice Address - City:PAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74058-3744
Practice Address - Country:US
Practice Address - Phone:918-762-6653
Practice Address - Fax:918-762-6656
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3469225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKQ26094Medicare UPIN
OK8HC641Medicare ID - Type Unspecified