Provider Demographics
NPI:1073500542
Name:CALICOTT, TIMOTHY W (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:W
Last Name:CALICOTT
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 1:14623 CHAMBERY DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-5586
Mailing Address - Country:US
Mailing Address - Phone:501-920-8556
Mailing Address - Fax:
Practice Address - Street 1:14623 CHAMBERY DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-5586
Practice Address - Country:US
Practice Address - Phone:501-920-8556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2012-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC8421207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR126098001Medicaid
ARF85198Medicare UPIN
AR126098001Medicaid