Provider Demographics
NPI:1083708440
Name:TICE, TIMOTHY V (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:V
Last Name:TICE
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:PO BOX 849
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93002-0849
Mailing Address - Country:US
Mailing Address - Phone:805-653-0088
Mailing Address - Fax:805-653-6748
Practice Address - Street 1:2580 E MAIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-2646
Practice Address - Country:US
Practice Address - Phone:805-653-0088
Practice Address - Fax:805-653-6748
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG637112084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
77-0566664OtherFEIN
77-0566664OtherFEIN