Provider Demographics
NPI:1710915012
Name:TILLMAN, TYWAUN KRETRICA (MD)
Entity type:Individual
Prefix:
First Name:TYWAUN
Middle Name:KRETRICA
Last Name:TILLMAN
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 1:38135 MARKET SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33542-7505
Mailing Address - Country:US
Mailing Address - Phone:352-567-0188
Mailing Address - Fax:813-355-5101
Practice Address - Street 1:4210 W LINEBAUGH AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624-5241
Practice Address - Country:US
Practice Address - Phone:813-884-0923
Practice Address - Fax:813-377-1006
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM8387207R00000X, 207RC0000X
FLME169173207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPENDINGOtherBLUE CROSS BLUE SHIELD
TXPENDINGMedicaid
TXH03752Medicare UPIN
TXP00469034Medicare PIN
TXPENDINGOtherBLUE CROSS BLUE SHIELD