Provider Demographics
NPI:1477632057
Name:FLAHERTY, TIMOTHY MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:MICHAEL
Last Name:FLAHERTY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 STONEHENGE DR
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-9334
Mailing Address - Country:US
Mailing Address - Phone:507-345-6172
Mailing Address - Fax:
Practice Address - Street 1:1881 E MADISON AVE
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6200
Practice Address - Country:US
Practice Address - Phone:507-388-9805
Practice Address - Fax:507-388-9812
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2486152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1880048OtherMAYO
MN22-00932OtherMEDICA
MN19979OtherSPECTERA
MN419000267Medicare PIN
MNU51455Medicare UPIN