Provider Demographics
NPI:1407027212
Name:DR. JAMES N. TISDALE, O.D., P.C.
Entity Type:Organization
Organization Name:DR. JAMES N. TISDALE, O.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:N
Authorized Official - Last Name:TISDALE
Authorized Official - Suffix:
Authorized Official - Credentials:OPTOMETRIST
Authorized Official - Phone:361-578-8441
Mailing Address - Street 1:114 PROFESSIONAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904-2351
Mailing Address - Country:US
Mailing Address - Phone:361-578-8441
Mailing Address - Fax:361-578-8494
Practice Address - Street 1:114 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-2351
Practice Address - Country:US
Practice Address - Phone:361-578-8441
Practice Address - Fax:361-578-8494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX02309TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDN6427OtherTHE RAILROAD RETIREMENT BOARD'S MEDICARE CARRIER
TX0064QTOtherBC/BS
TX440-56-97OtherAETNA
TX00E25AMedicare PIN
TX0064QTOtherBC/BS