Healthcare Provider Details

I. General information

NPI: 1710915012
Provider Name (Legal Business Name): TYWAUN KRETRICA TILLMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 02/07/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4210 W LINEBAUGH AVE
TAMPA FL
33624-5241
US

IV. Provider business mailing address

38135 MARKET SQUARE DR
ZEPHYRHILLS FL
33542-7505
US

V. Phone/Fax

Practice location:
  • Phone: 813-884-0923
  • Fax: 813-377-1006
Mailing address:
  • Phone: 352-567-0188
  • Fax: 813-355-5101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberM8387
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME169173
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberM8387
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberME169173
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: