Provider Demographics
NPI:1447307095
Name:TANNEHILL, MIKE (OD)
Entity type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:TANNEHILL
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:PO BOX 215
Mailing Address - Street 2:
Mailing Address - City:MOUNT IDA
Mailing Address - State:AR
Mailing Address - Zip Code:71957-9999
Mailing Address - Country:US
Mailing Address - Phone:870-867-2814
Mailing Address - Fax:
Practice Address - Street 1:138 S GEORGE ST
Practice Address - Street 2:
Practice Address - City:MT IDA
Practice Address - State:AR
Practice Address - Zip Code:71957-9999
Practice Address - Country:US
Practice Address - Phone:870-867-2814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2190152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR103820722Medicaid