Provider Demographics
NPI:1053309732
Name:TILLMAN, CLIFFORD RANDOLPH
Entity type:Individual
Prefix:DR
First Name:CLIFFORD
Middle Name:RANDOLPH
Last Name:TILLMAN
Suffix:
Gender:M
Credentials:
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:SUITE 2126
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:SUITE 2126
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:318-336-6074
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06980R207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0115585Medicaid
LA1316521Medicaid
MSC48308Medicare UPIN
LA5U434Medicare PIN
MS0115585Medicaid