1174730824 NPI number — DR. SYLVIA ELISE TILLMAN OD

Table of content: DR. SYLVIA ELISE TILLMAN OD (NPI 1174730824)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174730824 NPI number — DR. SYLVIA ELISE TILLMAN OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TILLMAN
Provider First Name:
SYLVIA
Provider Middle Name:
ELISE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHENHAV
Provider Other First Name:
SYLVIA
Provider Other Middle Name:
ELISE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
OD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174730824
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1521 LINDA SUE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ENCINITAS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92024-2424
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-634-7699
Provider Business Mailing Address Fax Number:
760-634-7699

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1521 LINDA SUE LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ENCINITAS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92024-2424
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-634-7699
Provider Business Practice Location Address Fax Number:
760-634-7699
Provider Enumeration Date:
05/16/2007

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: 152W00000X , with the licence number:  OPT9726T , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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