Provider Demographics
NPI:1073600987
Name:SANBORN, TIMOTHY A (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:A
Last Name:SANBORN
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 1:7901 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-2010
Mailing Address - Country:US
Mailing Address - Phone:414-346-8000
Mailing Address - Fax:414-346-8010
Practice Address - Street 1:6308 8TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143
Practice Address - Country:US
Practice Address - Phone:262-653-3650
Practice Address - Fax:262-656-3672
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036102493207RC0000X
WI69326207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1073600987Medicaid