Provider Demographics
NPI:1427099951
Name:HERRMANN, TYSON J (OD)
Entity type:Individual
Prefix:
First Name:TYSON
Middle Name:J
Last Name:HERRMANN
Suffix:
Gender:
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 N VERMILION ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-3094
Mailing Address - Country:US
Mailing Address - Phone:217-442-2631
Mailing Address - Fax:217-442-0119
Practice Address - Street 1:304 W HAY ST
Practice Address - Street 2:SUITE 311
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-6328
Practice Address - Country:US
Practice Address - Phone:217-698-3030
Practice Address - Fax:217-698-4728
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009537152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180022789OtherRR MEDICARE
IL046009537Medicaid
IL352450Medicare Oscar/Certification
K27568Medicare PIN
IL046009537Medicaid
IL352450Medicare Oscar/Certification