Basic Information
| Provider Information | |||||||||
| NPI: | 1952392086 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TILLEY | ||||||||
| FirstName: | EVERETT | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 E NORTH ST | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630251205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362004393 | ||||||||
| FaxNumber: | 6369382650 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 S JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | PERRYVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637752517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5735476233 | ||||||||
| FaxNumber: | 5735476765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 10/02/2014 | ||||||||
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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 | 152W00000X | T02317 | MO | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1952392086 | 05 | MO | MEDICAID |