Provider Demographics
NPI:1760443519
Name:TILAK, SAMIR S (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMIR
Middle Name:S
Last Name:TILAK
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 1:1307 WHITE HORSE RD
Mailing Address - Street 2:SUITE A-102
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-2176
Mailing Address - Country:US
Mailing Address - Phone:856-374-4031
Mailing Address - Fax:856-784-6307
Practice Address - Street 1:748 KINGS HWY
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-3157
Practice Address - Country:US
Practice Address - Phone:856-848-4998
Practice Address - Fax:856-848-9288
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA072373002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8539502Medicaid
NJH39222Medicare UPIN
NJ8539502Medicaid