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General NPI Number Information
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NPI Number | 1174546584
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Entity Type | Individual
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Provider Name | SUWARNA M TILAK MD
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Gender | Female
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Dates
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Enumeration Date | 07/26/2006
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Last Update Date | 11/18/2009
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Provider Practice Location Address
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Address Line | 10175 FORTUNE PKWY SUITE 401
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City | JACKSONVILLE
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State | FL
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Zip | 32256-6746
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Country | US
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Telephone | 904-519-0008
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Fax | 904-519-0007
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Provider Business Mailing Address
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Address Line | 430 COLLEGE DR SUITE 100-102
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City | MIDDLEBURG
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State | FL
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Zip | 32068-8530
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Country | US
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Telephone | 904-298-1994
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Fax | 904-298-1973
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | ME71441
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License Number State | FL
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