MEDICARE: DR. SUWARNA M TILAK MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	ME71441	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2941247	OTHER	FL	AETNA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	05527	OTHER	FL	HUMANA
4	211581	OTHER	FL	AVMED
5	32326	OTHER	FL	BCBS
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174546584
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUWARNA M TILAK MD

Provider Business Mailing Address
First Line	:	430 COLLEGE DR
Second Line	:	SUITE 100-102
City	:	MIDDLEBURG
State	:	FL
Zip	:	32068-8530
Country	:	US
Telephone Number	:	904-298-1994
Fax Number	:	904-298-1973

Provider Business Practice Location Address
First Line	:	10175 FORTUNE PKWY
Second Line	:	SUITE 401
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-6746
Country	:	US
Telephone Number	:	904-519-0008
Fax Number	:	904-519-0007

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	11/18/2009

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