Basic Information
| Provider Information | |||||||||
| NPI: | 1245349919 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TILLMAN | ||||||||
| FirstName: | MARSHALL | ||||||||
| MiddleName: | PERRY | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8614 WESTWOOD CENTER DR FL 9 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221822442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 812 W WADE HAMPTON BLVD | ||||||||
| Address2: | |||||||||
| City: | GREER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296501309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8648771825 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 08/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2109 | MN | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 2303 | SC | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 478523100 | 05 | MN | MEDICAID | 48379 | 01 | MN | DAVIS VISION | OTHER | 333471032669 | 01 | MN | PREFERRED ONE | OTHER | 52M69TI | 01 | MN | BLUE CROSS | OTHER | 15952 | 01 | MN | SPECTERA | OTHER | 22-01918 | 01 | MN | MEDICA | OTHER |