Provider Demographics
NPI:1215910088
Name:TILLEY, TOBIN B (OD)
Entity type:Individual
Prefix:
First Name:TOBIN
Middle Name:B
Last Name:TILLEY
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 1:708 HILL COUNTRY DR
Mailing Address - Street 2:#100
Mailing Address - City:KERVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-6071
Mailing Address - Country:US
Mailing Address - Phone:830-257-5656
Mailing Address - Fax:830-257-5856
Practice Address - Street 1:708 HILL COUNTRY DR
Practice Address - Street 2:#100
Practice Address - City:KERVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-6071
Practice Address - Country:US
Practice Address - Phone:830-257-5656
Practice Address - Fax:830-257-5856
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-25
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX03397TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX093365703Medicaid
TX093365703Medicaid
TX83540EMedicare PIN