1174546584 NPI number — DR. SUWARNA M TILAK MD

Table of content: DR. SUWARNA M TILAK MD (NPI 1174546584)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174546584 NPI number — DR. SUWARNA M TILAK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TILAK
Provider First Name:
SUWARNA
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TILAK
Provider Other First Name:
SUE
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1174546584
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/18/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
430 COLLEGE DR
Provider Second Line Business Mailing Address:
SUITE 100-102
Provider Business Mailing Address City Name:
MIDDLEBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32068-8530
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-298-1994
Provider Business Mailing Address Fax Number:
904-298-1973

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10175 FORTUNE PKWY
Provider Second Line Business Practice Location Address:
SUITE 401
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32256-6746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-519-0008
Provider Business Practice Location Address Fax Number:
904-519-0007
Provider Enumeration Date:
07/26/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  ME71441 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2941247 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 250510000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05527 . This is a "HUMANA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 211581 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 32326 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 250510000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".