Provider Demographics
NPI:1821198037
Name:TILLMAN, DONALD KENNETH JR (DO)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:KENNETH
Last Name:TILLMAN
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2708 STERNBERG DR
Mailing Address - Street 2:
Mailing Address - City:HAYS
Mailing Address - State:KS
Mailing Address - Zip Code:67601
Mailing Address - Country:US
Mailing Address - Phone:785-625-7546
Mailing Address - Fax:785-625-7598
Practice Address - Street 1:2708 STERNBERG DR
Practice Address - Street 2:
Practice Address - City:HAYS
Practice Address - State:KS
Practice Address - Zip Code:67601
Practice Address - Country:US
Practice Address - Phone:785-625-7546
Practice Address - Fax:785-625-7598
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0523958207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSE97022Medicare UPIN
KS016813Medicare ID - Type Unspecified