Provider Demographics
NPI:1356306658
Name:TILLER, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:TILLER
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 1:117 E LULLWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-2317
Mailing Address - Country:US
Mailing Address - Phone:202-425-2103
Mailing Address - Fax:
Practice Address - Street 1:3551 ROGER BROOKE DR
Practice Address - Street 2:
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:202-425-2103
Practice Address - Fax:215-243-4605
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301075583171000000X, 208600000X, 2086S0127X
PAMD457338208600000X, 2086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No171000000XOther Service ProvidersMilitary Health Care Provider
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC1356306658Medicaid