1962629824 NPI number — TIMOTHY A VAN DYNE DPM INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962629824 NPI number — TIMOTHY A VAN DYNE DPM INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIMOTHY A VAN DYNE DPM INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1962629824
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5777 N FRESNO ST
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
FRESNO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93710-6065
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-435-0261
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5777 N FRESNO ST
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
FRESNO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93710-6065
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-435-0261
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VAN DYNE
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
ALLEN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
559-435-0261

Provider Taxonomy Codes

  • Taxonomy code: 261QP1100X , with the licence number:  E2025 , 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: E2025 . This is a "MEDICARE ID 000E20250" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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