Provider Demographics
NPI:1477880664
Name:TILLER, MARC O (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:O
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:PO BOX 875
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:NY
Mailing Address - Zip Code:10990-0875
Mailing Address - Country:US
Mailing Address - Phone:845-294-2006
Mailing Address - Fax:845-615-1590
Practice Address - Street 1:15 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:NY
Practice Address - Zip Code:10990-1028
Practice Address - Country:US
Practice Address - Phone:845-294-2006
Practice Address - Fax:845-615-1590
Is Sole Proprietor?:No
Enumeration Date:2009-11-09
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2050577-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist