Provider Demographics
NPI:1306806799
Name:TILLER, EDWARD H (PHD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:H
Last Name:TILLER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:217 MCLAWS CIR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185-5855
Mailing Address - Country:US
Mailing Address - Phone:757-253-0371
Mailing Address - Fax:757-253-8063
Practice Address - Street 1:217 MCLAWS CIR
Practice Address - Street 2:SUITE 2
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-5855
Practice Address - Country:US
Practice Address - Phone:757-253-0371
Practice Address - Fax:757-253-8063
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810007422084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007753373Medicaid
VA006185E93Medicare ID - Type Unspecified