Provider Demographics
NPI:1770501280
Name:TILLERY, CARLA ROSE (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLA
Middle Name:ROSE
Last Name:TILLERY
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 1:1190 E NINE MILE RD
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-1651
Mailing Address - Country:US
Mailing Address - Phone:850-474-8771
Mailing Address - Fax:850-479-9180
Practice Address - Street 1:1190 E NINE MILE RD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-1651
Practice Address - Country:US
Practice Address - Phone:850-474-8771
Practice Address - Fax:850-479-9180
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78611207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL257288500Medicaid
H01483Medicare UPIN
492164Medicare ID - Type Unspecified