Healthcare Provider Details

I. General information

NPI: 1053309732
Provider Name (Legal Business Name): DR. CLIFFORD RANDOLPH TILLMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 07/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 FRONT ST SUITE 2126
VIDALIA LA
71373-2836
US

IV. Provider business mailing address

107 FRONT ST SUITE 2126
VIDALIA LA
71373-2836
US

V. Phone/Fax

Practice location:
  • Phone: 318-336-2216
  • Fax: 318-336-6074
Mailing address:
  • Phone: 318-336-2216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number06980R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: