1750596755 NPI number — MR. TIMOTHY EARL WILEY RDO

Table of content: MR. TIMOTHY EARL WILEY RDO (NPI 1750596755)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750596755 NPI number — MR. TIMOTHY EARL WILEY RDO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILEY
Provider First Name:
TIMOTHY
Provider Middle Name:
EARL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
RDO
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:
1750596755
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
980 S BAYWOOD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN JOSE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95128-3310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-985-8265
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
227 N JACKSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN JOSE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95116-1603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-729-7115
Provider Business Practice Location Address Fax Number:
408-729-7115
Provider Enumeration Date:
05/11/2007

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: 156F00000X , with the licence number:  D3539 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1713912 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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