Provider Demographics
NPI:1306805148
Name:TILTON, THOMAS WAYNE (DO)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:WAYNE
Last Name:TILTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 GATEWAY DR
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178
Mailing Address - Country:US
Mailing Address - Phone:815-756-8571
Mailing Address - Fax:815-756-1790
Practice Address - Street 1:2240 GATEWAY DR
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178
Practice Address - Country:US
Practice Address - Phone:815-756-8571
Practice Address - Fax:815-756-1790
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036090013207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036090013Medicaid
ILL73167OtherMEDICARE
IL036090013Medicaid
D93058Medicare UPIN