Provider Demographics
NPI:1033133517
Name:NEITZKE, TIMOTHY CHARLES (OD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:CHARLES
Last Name:NEITZKE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38004 N LITTLE MCDONALD DR
Mailing Address - Street 2:
Mailing Address - City:FRAZEE
Mailing Address - State:MN
Mailing Address - Zip Code:56544-8931
Mailing Address - Country:US
Mailing Address - Phone:218-346-5443
Mailing Address - Fax:
Practice Address - Street 1:340 FOX ST
Practice Address - Street 2:
Practice Address - City:PERHAM
Practice Address - State:MN
Practice Address - Zip Code:56573
Practice Address - Country:US
Practice Address - Phone:218-346-3310
Practice Address - Fax:218-346-9064
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2262152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN869723000Medicaid
MN410000675Medicare ID - Type Unspecified
MNT92379Medicare UPIN