1295938322 NPI number — MR. TIMOTHY STANLEY O'BRIEN PEDORTHIST

Table of content: MR. TIMOTHY STANLEY O'BRIEN PEDORTHIST (NPI 1295938322)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295938322 NPI number — MR. TIMOTHY STANLEY O'BRIEN PEDORTHIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
O'BRIEN
Provider First Name:
TIMOTHY
Provider Middle Name:
STANLEY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PEDORTHIST
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:
1295938322
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
245 S US HIGHWAY 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEQUESTA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33469-2701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-746-3536
Provider Business Mailing Address Fax Number:
561-144-7851

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2641 SE OCEAN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STUART
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34996-3401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-283-3833
Provider Business Practice Location Address Fax Number:
772-283-5632
Provider Enumeration Date:
06/06/2007

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: 174400000X , with the licence number:  PED73 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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