Provider Demographics
NPI:1962708305
Name:TILLO, MASINA
Entity type:Individual
Prefix:
First Name:MASINA
Middle Name:
Last Name:TILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:HELEN
Other - Last Name:OLSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4368 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602-2529
Mailing Address - Country:US
Mailing Address - Phone:510-531-1111
Mailing Address - Fax:510-530-8083
Practice Address - Street 1:4368 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94602-2529
Practice Address - Country:US
Practice Address - Phone:510-531-3111
Practice Address - Fax:510-530-8083
Is Sole Proprietor?:No
Enumeration Date:2011-02-02
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist