Provider Demographics
NPI:1447393301
Name:TILLINGHAST, JEFFREY PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:PAUL
Last Name:TILLINGHAST
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 1:969 N MASON RD STE 240
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6338
Mailing Address - Country:US
Mailing Address - Phone:314-542-0606
Mailing Address - Fax:314-542-0212
Practice Address - Street 1:969 N MASON RD STE 240
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6338
Practice Address - Country:US
Practice Address - Phone:314-542-0606
Practice Address - Fax:314-542-0212
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7B86207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO118205OtherHEALTHLINK
MO28644OtherBLUE SHIELD
MO030000959OtherRAILROAD MEDICARE
MOE27177Medicare UPIN
MO002011440Medicare ID - Type Unspecified