Provider Demographics
NPI:1073669339
Name:WEILL, TIMOTHY CLARK (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:CLARK
Last Name:WEILL
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 1:2003 KOOTENAI HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6051
Mailing Address - Country:US
Mailing Address - Phone:208-625-5085
Mailing Address - Fax:208-625-5731
Practice Address - Street 1:2003 KOOTENAI HEALTH WAY
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-6051
Practice Address - Country:US
Practice Address - Phone:208-625-6900
Practice Address - Fax:208-625-6910
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM12442208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0065739Medicaid
MTD20598Medicare UPIN
MT000083987Medicare ID - Type Unspecified