Provider Demographics
NPI:1164516001
Name:GARG, TILAK R (MD)
Entity Type:Individual
Prefix:
First Name:TILAK
Middle Name:R
Last Name:GARG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2945 ORCHARD LAKE RD
Mailing Address - Street 2:
Mailing Address - City:KEEGO HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48320-1458
Mailing Address - Country:US
Mailing Address - Phone:248-681-4200
Mailing Address - Fax:248-681-0818
Practice Address - Street 1:2945 ORCHARD LAKE RD
Practice Address - Street 2:
Practice Address - City:KEEGO HARBOR
Practice Address - State:MI
Practice Address - Zip Code:48320-1458
Practice Address - Country:US
Practice Address - Phone:248-681-4200
Practice Address - Fax:248-681-0818
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301036931208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1908316Medicaid
MI1908316Medicaid
MIA78260Medicare UPIN