Provider Demographics
NPI:1770567919
Name:TILLMAN, CAROL (OD)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:TILLMAN
Suffix:
Gender:
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7117 BROCKTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-2658
Mailing Address - Country:US
Mailing Address - Phone:951-782-5131
Mailing Address - Fax:951-784-3258
Practice Address - Street 1:7117 BROCKTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2615
Practice Address - Country:US
Practice Address - Phone:951-782-5131
Practice Address - Fax:951-784-3258
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT8639152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1730180415OtherGOUP NPI
SD0086390Medicare ID - Type Unspecified
U44883Medicare UPIN