Provider Demographics
NPI:1447307467
Name:REEDER, TILDEN (MD)
Entity type:Individual
Prefix:
First Name:TILDEN
Middle Name:
Last Name:REEDER
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 1:8875 COSTA VERDE BLVD APT 1419
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-6665
Mailing Address - Country:US
Mailing Address - Phone:609-240-4363
Mailing Address - Fax:
Practice Address - Street 1:15431 ANACAPA RD STE D
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-2458
Practice Address - Country:US
Practice Address - Phone:760-338-4341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD066602L2084P0800X, 2084P0804X
CAC369692084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001727974Medicaid
PA063319GNYMedicare ID - Type Unspecified