Provider Demographics
NPI:1497726475
Name:TILL, JONATHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:TILL
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 45923
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-5923
Mailing Address - Country:US
Mailing Address - Phone:877-969-0392
Mailing Address - Fax:
Practice Address - Street 1:3090 ELECTRIC RD
Practice Address - Street 2:SUITE B
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-3531
Practice Address - Country:US
Practice Address - Phone:540-772-3978
Practice Address - Fax:540-400-0001
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101040106207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006304427Medicaid
VAP00356490OtherMEDICARE RAILROAD LGP
VAP00277134OtherMEDICARE RAILROAD
VAB06493Medicare UPIN
VA00W734L60Medicare ID - Type UnspecifiedRICHMOND MEDICARE