Provider Demographics
NPI:1265578793
Name:TILLEY, SUBENA KAUR MAHAL (DO)
Entity type:Individual
Prefix:
First Name:SUBENA
Middle Name:KAUR MAHAL
Last Name:TILLEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39225 STATE ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1437
Mailing Address - Country:US
Mailing Address - Phone:510-794-1990
Mailing Address - Fax:510-794-3641
Practice Address - Street 1:39225 STATE ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1437
Practice Address - Country:US
Practice Address - Phone:510-794-1990
Practice Address - Fax:510-794-3641
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR43802207Q00000X
CA20A10442207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine