Provider Demographics
NPI:1932295748
Name:TILLMAN, LAURA (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:O'CONNOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 31001-0698
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-0698
Mailing Address - Country:US
Mailing Address - Phone:602-263-1511
Mailing Address - Fax:602-263-1619
Practice Address - Street 1:4212 NORTH 16TH STREET
Practice Address - Street 2:DEPARTMENT OF SURGERY
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016
Practice Address - Country:US
Practice Address - Phone:602-263-1511
Practice Address - Fax:602-263-1637
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ24835208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ483537Medicaid
AZAZ0722860OtherBCBS
AZ483537Medicaid
AZ030078Medicare Oscar/Certification
AZH45197Medicare UPIN