Healthcare Provider Details

I. General information

NPI: 1518753607
Provider Name (Legal Business Name): TILO THOTTAKARA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2025
Last Update Date: 05/05/2025
Certification Date: 05/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 HAWTHORNE AVE
OAKLAND CA
94609-3108
US

IV. Provider business mailing address

350 HAWTHORNE AVE
OAKLAND CA
94609-3108
US

V. Phone/Fax

Practice location:
  • Phone: 415-589-9036
  • Fax:
Mailing address:
  • Phone: 510-869-8751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: