Provider Demographics
NPI:1366486722
Name:MARTIN, TIMOTHY J (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:J
Last Name:MARTIN
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 1:1050 W 10TH ST
Mailing Address - Street 2:ATTN: EXECUTIVE DIRECTOR OF PHYSICIAN CLINICS
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-2905
Mailing Address - Country:US
Mailing Address - Phone:573-364-9000
Mailing Address - Fax:
Practice Address - Street 1:1050 W 10TH ST STE 500
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401
Practice Address - Country:US
Practice Address - Phone:573-308-1301
Practice Address - Fax:573-202-2480
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101609207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO010910183Medicaid
MO010910183Medicaid
MO000093029Medicare PIN
MO010910183Medicare PIN
MO023012057Medicare PIN