=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750553426
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GAURI S. TILAK MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2008
-----------------------------------------------------
Last Update Date | 04/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1005 JOE DIMAGGIO DR
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33021-5402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-265-5892
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 N HIATUS RD STE 200
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33026-5213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-437-4800
-----------------------------------------------------
Fax | 954-437-6628
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085P0229X
-----------------------------------------------------
Taxonomy Name | Pediatric Radiology Physician
-----------------------------------------------------
License Number | 269581
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 54592
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------