Provider Demographics
NPI:1154385029
Name:TILLO, TIMOTHY H (DPM)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:H
Last Name:TILLO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3117 SPRING GLEN RD
Mailing Address - Street 2:STE 402
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-5906
Mailing Address - Country:US
Mailing Address - Phone:904-224-2001
Mailing Address - Fax:904-224-2002
Practice Address - Street 1:12276 SAN JOSE BLVD
Practice Address - Street 2:STE 606
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8672
Practice Address - Country:US
Practice Address - Phone:904-224-2001
Practice Address - Fax:904-260-1523
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO1862213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
65019ZMedicare PIN
21698AMedicare PIN
21698BMedicare PIN
65019YMedicare PIN
FL0413700006Medicare NSC
FLT86304Medicare UPIN