Provider Demographics
NPI:1275630626
Name:TILLMAN, CHARLES P JR (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:P
Last Name:TILLMAN
Suffix:JR
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:PO BOX 225
Mailing Address - Street 2:3126 E ROANE AVE
Mailing Address - City:EUPORA
Mailing Address - State:MS
Mailing Address - Zip Code:39744-0225
Mailing Address - Country:US
Mailing Address - Phone:662-258-2020
Mailing Address - Fax:662-258-2030
Practice Address - Street 1:3126 E ROANE AVE
Practice Address - Street 2:
Practice Address - City:EUPORA
Practice Address - State:MS
Practice Address - Zip Code:39744-2638
Practice Address - Country:US
Practice Address - Phone:662-258-2020
Practice Address - Fax:662-258-2030
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS519152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0087039Medicaid
LA1772968Medicaid
LA1772968Medicaid
MS410000174Medicare ID - Type Unspecified