Provider Demographics
NPI:1104001833
Name:STANSBURY, TIMOTHY JACK (RT (R))
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:JACK
Last Name:STANSBURY
Suffix:
Gender:M
Credentials:RT (R)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 PEARL DR
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:MO
Mailing Address - Zip Code:63050-5032
Mailing Address - Country:US
Mailing Address - Phone:636-797-5983
Mailing Address - Fax:
Practice Address - Street 1:915 N GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63106-1621
Practice Address - Country:US
Practice Address - Phone:314-652-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-31
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO3768282471C3402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography