Provider Demographics
NPI:1699237230
Name:TILLMAN, RODERICK
Entity type:Individual
Prefix:
First Name:RODERICK
Middle Name:
Last Name:TILLMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3880 GREENHOUSE RD STE 406
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77084-3486
Mailing Address - Country:US
Mailing Address - Phone:281-944-5951
Mailing Address - Fax:832-565-1413
Practice Address - Street 1:423 MASON PARK BLVD STE C
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77450-6227
Practice Address - Country:US
Practice Address - Phone:281-944-5951
Practice Address - Fax:832-565-1413
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-02
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor