Provider Demographics
NPI:1477554277
Name:ISERI, TIMOTHY MATTHEW (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:MATTHEW
Last Name:ISERI
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 1:927 S CARMEL ST
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-2547
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:927 CARMEL ST
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-2547
Practice Address - Country:US
Practice Address - Phone:231-876-3876
Practice Address - Fax:231-775-1115
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22588208600000X
IDM7982208600000X
MI4301065506208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR288205Medicaid
ID805805300Medicaid
020H310060OtherBCBS
MI4890725Medicaid
H24594Medicare UPIN
0M76010Medicare ID - Type Unspecified
ID805805300Medicaid
MI4890725Medicaid