Provider Demographics
NPI:1548214687
Name:TILLEY, LAWRENCE EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:EDWARD
Last Name:TILLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23000 MOAKLEY ST
Mailing Address - Street 2:#203
Mailing Address - City:LEONARDTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20650-2915
Mailing Address - Country:US
Mailing Address - Phone:301-475-8599
Mailing Address - Fax:301-475-1514
Practice Address - Street 1:23000 MOAKLEY ST
Practice Address - Street 2:#203
Practice Address - City:LEONARDTOWN
Practice Address - State:MD
Practice Address - Zip Code:20650-2915
Practice Address - Country:US
Practice Address - Phone:301-475-8599
Practice Address - Fax:301-475-1514
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD28647207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
2589469OtherAETNA
LY13LAOtherBLUE SHIELD, MD
1405390004OtherCIGNA
479847OtherMAMSI
R031OtherBLUE SHIELD, DC
2589469OtherAETNA