Provider Demographics
NPI:1043577315
Name:TILLY, MONICA
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:TILLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MONICA
Other - Middle Name:
Other - Last Name:KAITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 7464
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94120-7464
Mailing Address - Country:US
Mailing Address - Phone:415-206-6581
Mailing Address - Fax:
Practice Address - Street 1:1001 POTRERO AVE BLDG 9
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-3518
Practice Address - Country:US
Practice Address - Phone:415-206-6581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-11
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1229262083P0901X, 2083X0100X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine