Provider Demographics
NPI:1699070987
Name:TILLEY, CHRISTOPHER JAMES (IDC)
Entity type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:JAMES
Last Name:TILLEY
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 CRAVEN ST
Mailing Address - Street 2:BLDG 3300
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92136-5599
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2450 CRAVEN ST
Practice Address - Street 2:BLDG 3300
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92136-5599
Practice Address - Country:US
Practice Address - Phone:619-532-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-18
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman