Healthcare Provider Details

I. General information

NPI: 1174546584
Provider Name (Legal Business Name): SUWARNA M TILAK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUE M TILAK MD

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 11/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10175 FORTUNE PKWY SUITE 401
JACKSONVILLE FL
32256-6746
US

IV. Provider business mailing address

430 COLLEGE DR SUITE 100-102
MIDDLEBURG FL
32068-8530
US

V. Phone/Fax

Practice location:
  • Phone: 904-519-0008
  • Fax: 904-519-0007
Mailing address:
  • Phone: 904-298-1994
  • Fax: 904-298-1973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME71441
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: