Healthcare Provider Details

I. General information

NPI: 1134102320
Provider Name (Legal Business Name): STEVEN GARY TILLETT D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6274 SW CAPITOL HWY
PORTLAND OR
97239-2674
US

IV. Provider business mailing address

6274 SW CAPITOL HWY
PORTLAND OR
97239-2674
US

V. Phone/Fax

Practice location:
  • Phone: 503-246-2212
  • Fax:
Mailing address:
  • Phone: 503-246-2212
  • Fax: 503-246-4050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberDP00300
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: