Provider Demographics
NPI:1891820080
Name:TILLEY, IAN BRENT
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:BRENT
Last Name:TILLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 S OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-3023
Mailing Address - Country:US
Mailing Address - Phone:213-746-1037
Mailing Address - Fax:213-746-9379
Practice Address - Street 1:1530 S OLIVE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-3023
Practice Address - Country:US
Practice Address - Phone:213-746-1037
Practice Address - Fax:213-746-9379
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA94720207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABT9642364OtherDEA