Provider Demographics
NPI:1114141330
Name:OLDENKAMP, TIMOTHY DOUGLAS (PT)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DOUGLAS
Last Name:OLDENKAMP
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 MAIN STREET
Mailing Address - Street 2:PO BOX 40
Mailing Address - City:STARBUCK
Mailing Address - State:MN
Mailing Address - Zip Code:56381
Mailing Address - Country:US
Mailing Address - Phone:320-239-2217
Mailing Address - Fax:320-239-7144
Practice Address - Street 1:605 MAIN STREET
Practice Address - Street 2:
Practice Address - City:STARBUCK
Practice Address - State:MN
Practice Address - Zip Code:56381
Practice Address - Country:US
Practice Address - Phone:320-239-2217
Practice Address - Fax:320-239-7144
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7086174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN057H8OLOtherBLUE CROSSBLUE SHIELD
MN122234OtherUCARE
MN6406167OtherMEDICA
MN245537Medicare ID - Type UnspecifiedGROUP ID