Provider Demographics
NPI:1710915012
Name:TILLMAN, TYWAUN (MD)
Entity Type:Individual
Prefix:
First Name:TYWAUN
Middle Name:
Last Name:TILLMAN
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 1:2700 CITIZENS PLZ
Mailing Address - Street 2:SUITE 300
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-5754
Mailing Address - Country:US
Mailing Address - Phone:361-573-0756
Mailing Address - Fax:361-573-0633
Practice Address - Street 1:2700 CITIZENS PLZ
Practice Address - Street 2:SUITE 300
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-5754
Practice Address - Country:US
Practice Address - Phone:361-573-0756
Practice Address - Fax:361-573-0633
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM8387207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPENDINGOtherBLUE CROSS BLUE SHIELD
TXPENDINGMedicaid
TXH03752Medicare UPIN
TXP00469034Medicare PIN
TXPENDINGOtherBLUE CROSS BLUE SHIELD