Provider Demographics
NPI:1174546584
Name:TILAK, SUWARNA M (MD)
Entity type:Individual
Prefix:DR
First Name:SUWARNA
Middle Name:M
Last Name:TILAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SUE
Other - Middle Name:M
Other - Last Name:TILAK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:430 COLLEGE DR
Mailing Address - Street 2:SUITE 100-102
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-8530
Mailing Address - Country:US
Mailing Address - Phone:904-298-1994
Mailing Address - Fax:904-298-1973
Practice Address - Street 1:10175 FORTUNE PKWY
Practice Address - Street 2:SUITE 401
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-6746
Practice Address - Country:US
Practice Address - Phone:904-519-0008
Practice Address - Fax:904-519-0007
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME71441208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2941247OtherAETNA
FL250510000Medicaid
FL05527OtherHUMANA
FL211581OtherAVMED
FL32326OtherBCBS
FL211581OtherAVMED