1093789752 NPI number — TIMOTHY M WESTGATE O. D.

Table of content: TIMOTHY M WESTGATE O. D. (NPI 1093789752)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093789752 NPI number — TIMOTHY M WESTGATE O. D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WESTGATE
Provider First Name:
TIMOTHY
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O. D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093789752
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
885 S GOVERNORS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOVER
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19904-4158
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-734-5861
Provider Business Mailing Address Fax Number:
302-734-1921

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1301 BRIDGEVILLE HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEAFORD
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19973-1616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-629-9197
Provider Business Practice Location Address Fax Number:
302-629-3335
Provider Enumeration Date:
02/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  130001190 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: G00016 . This is a "MEDICARE GROUP PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: I3-0001190 . This is a "LICENSE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 000A74H16 . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 11220847 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1245251313 . This is a "MEDICARE GROUP NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000214822 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".




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