Provider Demographics
NPI:1689833279
Name:TILLMAN, JULIE A (MD)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:A
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:A
Other - Last Name:MOLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11123 PARKVIEW PLAZA DR
Practice Address - Street 2:SUITE 101
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1707
Practice Address - Country:US
Practice Address - Phone:260-425-6650
Practice Address - Fax:260-425-6649
Is Sole Proprietor?:No
Enumeration Date:2008-06-09
Last Update Date:2022-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01069641A207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN11013722OtherTEMPORARY MEDICAL LICENSE