Provider Demographics
NPI:1902420011
Name:QUALLS, TANYA CHUGH (OD)
Entity Type:Individual
Prefix:DR
First Name:TANYA
Middle Name:CHUGH
Last Name:QUALLS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 W TOWN CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-1248
Mailing Address - Country:US
Mailing Address - Phone:217-531-5393
Mailing Address - Fax:
Practice Address - Street 1:525 W TOWN CENTER BLVD
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-1248
Practice Address - Country:US
Practice Address - Phone:217-531-5393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-04
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046011429152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist