Basic Information
| Provider Information | |||||||||
| NPI: | 1245229145 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TABBUT | ||||||||
| FirstName: | BYRON | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3192 WILLOW CREEK RD | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863016610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287781234 | ||||||||
| FaxNumber: | 9287783999 | ||||||||
| Practice Location | |||||||||
| Address1: | 2015 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WHEATON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601873152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306688250 | ||||||||
| FaxNumber: | 6306688916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2005 | ||||||||
| LastUpdateDate: | 05/10/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 036-072686 | IL | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 180012231 | 01 | IL | RR MEDICARE | OTHER | 036072686 | 05 | IL | MEDICAID |