Provider Demographics
NPI:1114986098
Name:WEICHERT, TIMOTHY R (DO, PHD,FACOI)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:R
Last Name:WEICHERT
Suffix:
Gender:M
Credentials:DO, PHD,FACOI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3537 W FRONT ST STE I
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-9651
Mailing Address - Country:US
Mailing Address - Phone:231-935-8950
Mailing Address - Fax:231-935-8868
Practice Address - Street 1:3537 W FRONT ST STE I
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-9651
Practice Address - Country:US
Practice Address - Phone:231-935-8950
Practice Address - Fax:231-935-8868
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012287207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1152800585OtherBCBSM
MI3363234Medicaid
110152828OtherRR MEDICARE
MI3363234Medicaid
MI1152800585OtherBCBSM
MIG52008Medicare UPIN