Provider Demographics
NPI:1457349110
Name:TILLMAN, BARRY FORREST (MD)
Entity Type:Individual
Prefix:DR
First Name:BARRY
Middle Name:FORREST
Last Name:TILLMAN
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 1:107 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:LA
Mailing Address - Zip Code:71373-2836
Mailing Address - Country:US
Mailing Address - Phone:318-336-2216
Mailing Address - Fax:
Practice Address - Street 1:107 FRONT ST
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:LA
Practice Address - Zip Code:71373-2836
Practice Address - Country:US
Practice Address - Phone:318-336-2216
Practice Address - Fax:318-336-6075
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07480R207RP1001X
MS11444207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1371483Medicaid
MS0115584Medicaid
MS290000013Medicare PIN
MS0115584Medicaid
LA1371483Medicaid