Provider Demographics
NPI:1962597385
Name:TILLMAN, OTIS EDWARD JR (MD)
Entity type:Individual
Prefix:DR
First Name:OTIS
Middle Name:EDWARD
Last Name:TILLMAN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1942 NORTH AVENUE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901
Mailing Address - Country:US
Mailing Address - Phone:706-596-1245
Mailing Address - Fax:706-576-4245
Practice Address - Street 1:1942 NORTH AVENUE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901
Practice Address - Country:US
Practice Address - Phone:706-596-1245
Practice Address - Fax:706-576-4245
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA040576174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA224251OtherBCBS OF GEORGIA
AL60027547OtherBCBS OF ALABAMA
GA00669127CMedicaid
GA11BDWKPMedicare ID - Type Unspecified
GA224251OtherBCBS OF GEORGIA