Provider Demographics
NPI:1912071762
Name:WATERS, TILENA BROOKE (OD)
Entity Type:Individual
Prefix:DR
First Name:TILENA
Middle Name:BROOKE
Last Name:WATERS
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 1:315 PARHAM ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:MUSCATINE
Mailing Address - State:IA
Mailing Address - Zip Code:52761-2604
Mailing Address - Country:US
Mailing Address - Phone:563-263-7577
Mailing Address - Fax:563-263-7814
Practice Address - Street 1:315 PARHAM ST
Practice Address - Street 2:SUITE B
Practice Address - City:MUSCATINE
Practice Address - State:IA
Practice Address - Zip Code:52761-2604
Practice Address - Country:US
Practice Address - Phone:563-263-7577
Practice Address - Fax:563-263-7814
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02362152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist