Provider Demographics
NPI:1457330276
Name:TILLMAN, ROBERT E (OD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:E
Last Name:TILLMAN
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 1:2304 S MAIN ST
Mailing Address - Street 2:TILLMAN OPTOMETRY
Mailing Address - City:RICE LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54868-2900
Mailing Address - Country:US
Mailing Address - Phone:715-736-1700
Mailing Address - Fax:
Practice Address - Street 1:2304 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RICE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54868-2900
Practice Address - Country:US
Practice Address - Phone:715-736-1700
Practice Address - Fax:715-736-1703
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-11
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1491035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38563500Medicaid
000287430Medicare PIN
T63517Medicare UPIN