Provider Demographics
NPI:1245349919
Name:TILLMAN, MARSHALL PERRY (OD)
Entity type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:PERRY
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 1:8614 WESTWOOD CENTER DR FL 9
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2442
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:
Practice Address - Street 1:812 W WADE HAMPTON BLVD
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-1309
Practice Address - Country:US
Practice Address - Phone:864-877-1825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2109152W00000X
SC2303152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN478523100Medicaid
MN48379OtherDAVIS VISION
MN333471032669OtherPREFERRED ONE
MN52M69TIOtherBLUE CROSS
MN15952OtherSPECTERA
MN22-01918OtherMEDICA