MEDICARE: DR. THERON C TILGNER D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician	3501	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1497724413
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THERON C TILGNER D.O.

Provider Business Mailing Address
First Line	:	387 LAKE HAVASU AVE S STE 101
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-9306
Country	:	US
Telephone Number	:	928-854-3333
Fax Number	:	928-854-3335

Provider Business Practice Location Address
First Line	:	387 LAKE HAVASU AVE S STE 101
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-9306
Country	:	US
Telephone Number	:	928-854-3333
Fax Number	:	928-854-3335

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	02/26/2025

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