Provider Demographics
NPI:1134102320
Name:TILLETT, STEVEN GARY (DPM)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:GARY
Last Name:TILLETT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6274 SW CAPITOL HWY
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-2674
Mailing Address - Country:US
Mailing Address - Phone:503-246-2212
Mailing Address - Fax:503-246-4050
Practice Address - Street 1:6274 SW CAPITOL HWY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-2674
Practice Address - Country:US
Practice Address - Phone:503-246-2212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-22
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00300213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
831001001OtherBC
480031007OtherRR MEDICARE
OR227113OtherOMAP
OR227113Medicaid
480031007OtherRR MEDICARE
831001001OtherBC
R112771Medicare PIN