Provider Demographics
NPI:1922230614
Name:TILLEY, GINA ZAREENA KHAN (MD)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:ZAREENA KHAN
Last Name:TILLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ZAREENA
Other - Middle Name:K
Other - Last Name:BOZEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1003 SCHNEIDER DR
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:AR
Mailing Address - Zip Code:72104-4811
Mailing Address - Country:US
Mailing Address - Phone:501-337-5678
Mailing Address - Fax:501-332-6759
Practice Address - Street 1:1003 SCHNEIDER DR
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-4811
Practice Address - Country:US
Practice Address - Phone:501-337-5678
Practice Address - Fax:501-332-6759
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-14
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK34139207Q00000X
MEMD23125207Q00000X
NY300283207Q00000X
NJ25MA10731900207Q00000X
IL036.153880207Q00000X
TN61889207Q00000X
ARE-5303207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR179446001Medicaid
AR5H970C606Medicare PIN