Provider Demographics
NPI:1174595318
Name:TILLIS, TINA NANNETTE (MD)
Entity type:Individual
Prefix:DR
First Name:TINA
Middle Name:NANNETTE
Last Name:TILLIS
Suffix:
Gender:F
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:P O BOX 10525
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32247-0525
Mailing Address - Country:US
Mailing Address - Phone:904-345-3473
Mailing Address - Fax:
Practice Address - Street 1:3890 DUNN AVE
Practice Address - Street 2:#902
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-6428
Practice Address - Country:US
Practice Address - Phone:904-345-3473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME64518207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3732029-00Medicaid
FLP00061611OtherRAILROAD MEDICARE
GA000581941FMedicaid
FL23164XMedicare PIN
GA000581941FMedicaid
FL23164YMedicare PIN