Provider Demographics
NPI:1003824632
Name:MARTINDALE, TIMOTHY (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:MARTINDALE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 20308
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76702-0308
Mailing Address - Country:US
Mailing Address - Phone:254-741-1113
Mailing Address - Fax:254-741-1342
Practice Address - Street 1:7104 NEW SANGER RD
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-3928
Practice Address - Country:US
Practice Address - Phone:254-741-1113
Practice Address - Fax:254-741-1342
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2959207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX040481601Medicaid
TX8A6564OtherBLUE CROSS AND BLUE SHIEL
TX092314601Medicaid
TX00N59XOtherBLUE CROSS BLUE SHIELD
TX080181687OtherMEDICARE RAILROAD
TX00N59XMedicare PIN
TX040481601Medicaid
TX092314601Medicaid