Provider Demographics
NPI:1760430938
Name:TISDAL, PAUL C (OD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:C
Last Name:TISDAL
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 1:1545 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:OK
Mailing Address - Zip Code:73096-2518
Mailing Address - Country:US
Mailing Address - Phone:580-772-2819
Mailing Address - Fax:580-772-2805
Practice Address - Street 1:1545 N. WASHINGTON
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:OK
Practice Address - Zip Code:73096-0308
Practice Address - Country:US
Practice Address - Phone:580-772-2819
Practice Address - Fax:580-772-2805
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1016152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200069320Medicaid
OK200069320Medicaid