Provider Demographics
NPI:1194920967
Name:DRS. TIDWELL, FAULKS, AND ALLEN - OPTOMETRY, PLLC
Entity type:Organization
Organization Name:DRS. TIDWELL, FAULKS, AND ALLEN - OPTOMETRY, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED INSURANCE TECH AND DATA E
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:615-446-2020
Mailing Address - Street 1:610 HENSLEE DR
Mailing Address - Street 2:
Mailing Address - City:DICKSON
Mailing Address - State:TN
Mailing Address - Zip Code:37055-1211
Mailing Address - Country:US
Mailing Address - Phone:615-446-2020
Mailing Address - Fax:615-441-2020
Practice Address - Street 1:610 HENSLEE DR
Practice Address - Street 2:
Practice Address - City:DICKSON
Practice Address - State:TN
Practice Address - Zip Code:37055-1211
Practice Address - Country:US
Practice Address - Phone:615-446-2020
Practice Address - Fax:615-441-2020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3119266OtherDR DAVID FAULKS BCBST
TN3595699Medicaid
TN3942446Medicaid
TN3595690OtherMEDICARE JERRY TIDWELL
TN3113993OtherDR JERRY TIDWELL BCBST
TNQ007418Medicaid
TN6022728OtherDR ALLEN BCBST
TN3113988OtherTIDWELL AND FAULKS BCBST
TNT61264Medicare UPIN
TN3942592Medicare ID - Type UnspecifiedTIDWELL AND FAULKS
TN3595690Medicaid