Provider Demographics
NPI:1467580225
Name:TILLINGHAST, STANLEY JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:JAMES
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 1:2413 RIVENDELL LN
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-3058
Mailing Address - Country:US
Mailing Address - Phone:650-400-3105
Mailing Address - Fax:
Practice Address - Street 1:2413 RIVENDELL LN
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-3058
Practice Address - Country:US
Practice Address - Phone:650-400-3105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI15000207RC0000X
CAG039776207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI629917-01Medicaid
HI0000282038OtherHMSA BILLING NUMBER
HI629917-01Medicaid