Provider Demographics
NPI:1902976061
Name:TILLMAN, FREDERICK W (OD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:W
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 1:806 DIXIE ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-4416
Mailing Address - Country:US
Mailing Address - Phone:770-834-2071
Mailing Address - Fax:770-834-1007
Practice Address - Street 1:806 DIXIE ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4416
Practice Address - Country:US
Practice Address - Phone:770-834-2071
Practice Address - Fax:770-834-1007
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAT968152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAT98095Medicare UPIN
GA55493154SAMedicare ID - Type Unspecified