Provider Demographics
NPI:1700852241
Name:TILLERY, BERTRAND JR (MD)
Entity Type:Individual
Prefix:DR
First Name:BERTRAND
Middle Name:
Last Name:TILLERY
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:4001 GEN DEGAULLE DR
Mailing Address - Street 2:SUITE H
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70114-8220
Mailing Address - Country:US
Mailing Address - Phone:504-365-9906
Mailing Address - Fax:504-365-9902
Practice Address - Street 1:4001 GEN DEGAULLE DR STE H
Practice Address - Street 2:SUITE H
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70114-8298
Practice Address - Country:US
Practice Address - Phone:504-365-9906
Practice Address - Fax:504-365-9902
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-24
Last Update Date:2016-10-14
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Provider Licenses
StateLicense IDTaxonomies
LA025561207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAH43332Medicare UPIN