Provider Demographics
NPI:1073629283
Name:CLINES, TIMOTHY RAY (OD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:RAY
Last Name:CLINES
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 1:1657 STONEY CREEK CT
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-6143
Mailing Address - Country:US
Mailing Address - Phone:219-531-1624
Mailing Address - Fax:
Practice Address - Street 1:1555 US HIGHWAY 41
Practice Address - Street 2:
Practice Address - City:SCHERERVILLE
Practice Address - State:IN
Practice Address - Zip Code:46375-1317
Practice Address - Country:US
Practice Address - Phone:219-865-6140
Practice Address - Fax:219-865-9053
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002436152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN151800Medicare PIN
IN408370Medicare PIN
INU55693Medicare UPIN