Healthcare Provider Details

I. General information

NPI: 1003090382
Provider Name (Legal Business Name): JOHN WILLIAM TILLETT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2007
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 E HARVARD AVE STE 305
DENVER CO
80210-5076
US

IV. Provider business mailing address

850 E HARVARD AVE STE 305
DENVER CO
80210-5076
US

V. Phone/Fax

Practice location:
  • Phone: 303-825-8822
  • Fax: 303-825-4022
Mailing address:
  • Phone: 303-825-8822
  • Fax: 303-825-4022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberME101754
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberDR.56872
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: