Provider Demographics
NPI:1093789752
Name:WESTGATE, TIMOTHY M (O D)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:M
Last Name:WESTGATE
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:885 S GOVERNORS AVE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-4158
Mailing Address - Country:US
Mailing Address - Phone:302-734-5861
Mailing Address - Fax:302-734-1921
Practice Address - Street 1:1301 BRIDGEVILLE HWY
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:DE
Practice Address - Zip Code:19973-1616
Practice Address - Country:US
Practice Address - Phone:302-629-9197
Practice Address - Fax:302-629-3335
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE130001190152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
G00016OtherMEDICARE GROUP PIN
DEI3-0001190OtherLICENSE
000A74H16OtherMEDICARE PTAN
11220847OtherCAQH
1245251313OtherMEDICARE GROUP NPI
DE000214822Medicaid
DEI3-0001190OtherLICENSE
DE000214822Medicaid
51-0270915OtherFEDERAL EIN