Provider Demographics
NPI:1427260256
Name:PAUL C. TISDAL, O.D., P.C.
Entity type:Organization
Organization Name:PAUL C. TISDAL, O.D., P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:CARROLL
Authorized Official - Last Name:TISDAL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:580-772-2819
Mailing Address - Street 1:P.O. BOX 308
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:OK
Mailing Address - Zip Code:73096
Mailing Address - Country:US
Mailing Address - Phone:580-772-2819
Mailing Address - Fax:580-772-2805
Practice Address - Street 1:1545 N. WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:OK
Practice Address - Zip Code:73096
Practice Address - Country:US
Practice Address - Phone:158-072-2819
Practice Address - Fax:158-077-2280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1016152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1760430938OtherNPI TYPE 1