Provider Demographics
NPI:1568925816
Name:TILLMAN, MONIQUA SHANTAL (MD)
Entity Type:Individual
Prefix:
First Name:MONIQUA
Middle Name:SHANTAL
Last Name:TILLMAN
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 1:625 19TH STREET SOUTH35249
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35249-5019
Mailing Address - Country:US
Mailing Address - Phone:601-622-3857
Mailing Address - Fax:
Practice Address - Street 1:625 19TH STREET SOUTH35249
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35249-5019
Practice Address - Country:US
Practice Address - Phone:205-996-6170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-12
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program