Provider Demographics
NPI:1912221359
Name:TILARA, AMISH (MD)
Entity Type:Individual
Prefix:DR
First Name:AMISH
Middle Name:
Last Name:TILARA
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 1:1873 ROYAL TROON CT
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-5234
Mailing Address - Country:US
Mailing Address - Phone:973-632-8372
Mailing Address - Fax:
Practice Address - Street 1:600 PROFESSIONAL DR
Practice Address - Street 2:SUITE 160A
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-7651
Practice Address - Country:US
Practice Address - Phone:973-632-8372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-14
Last Update Date:2015-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA728362085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology