Provider Demographics
NPI:1518054352
Name:TILAK, MARY (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:TILAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2241 45TH ST
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46322-2601
Mailing Address - Country:US
Mailing Address - Phone:219-922-8051
Mailing Address - Fax:219-922-8608
Practice Address - Street 1:2241 45TH ST
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322-2601
Practice Address - Country:US
Practice Address - Phone:219-922-8051
Practice Address - Fax:219-922-8608
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01054662A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200339190Medicaid
IN000000350970OtherANTHEM
IL90001352OtherBC/BS
IN000000541656OtherANTHEM
IN000000541656OtherANTHEM
IL90001352OtherBC/BS
IN253370AMedicare PIN
IN142650HMedicare PIN