Provider Demographics
NPI:1649256850
Name:TILLOTSON, MARK (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:TILLOTSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-7840
Mailing Address - Fax:704-384-7830
Practice Address - Street 1:257 HOSPITAL DRIVE SUITE 200
Practice Address - Street 2:
Practice Address - City:BOLIVIA
Practice Address - State:NC
Practice Address - Zip Code:28422-8411
Practice Address - Country:US
Practice Address - Phone:910-721-4000
Practice Address - Fax:910-721-4001
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36841208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC36841OtherNC LICENSE
NC8983552Medicaid
NCCJ2612Medicare UPIN
NC36841OtherNC LICENSE
NC2186461DMedicare PIN