1710480041 NPI number — MR. TIMOTHY SCOTT KEIDEL JR. DO

Table of content: MR. TIMOTHY SCOTT KEIDEL JR. DO (NPI 1710480041)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710480041 NPI number — MR. TIMOTHY SCOTT KEIDEL JR. DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KEIDEL
Provider First Name:
TIMOTHY
Provider Middle Name:
SCOTT
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KEIDEL
Provider Other First Name:
SCOTT
Provider Other Middle Name:
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1710480041
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2120 SW 22ND PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OCALA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34471-7765
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-732-5042
Provider Business Mailing Address Fax Number:
527-326-0313

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2120 SW 22ND PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OCALA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34471-7765
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-732-5042
Provider Business Practice Location Address Fax Number:
352-732-6031
Provider Enumeration Date:
03/13/2018

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: 207YX0007X , with the licence number:  OS20246 , 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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