Provider Demographics
NPI:1184916389
Name:VANESSA TILLEY CHRISTOPHERSON OD PLLC
Entity type:Organization
Organization Name:VANESSA TILLEY CHRISTOPHERSON OD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:TILLEY
Authorized Official - Last Name:CHRISTOPHERSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:214-503-0997
Mailing Address - Street 1:6419 SKILLMAN ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-7109
Mailing Address - Country:US
Mailing Address - Phone:214-503-0997
Mailing Address - Fax:
Practice Address - Street 1:6419 SKILLMAN ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-7109
Practice Address - Country:US
Practice Address - Phone:214-503-0997
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-05
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6883TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX205444702Medicaid