Provider Demographics
NPI:1487680419
Name:EICHENLAUB, TIMOTHY J (DO)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:EICHENLAUB
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:941-202-0500
Mailing Address - Fax:941-202-0501
Practice Address - Street 1:1287 US HIGHWAY 41 BYP S
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-5545
Practice Address - Country:US
Practice Address - Phone:941-202-0500
Practice Address - Fax:941-202-0501
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS010086L207Q00000X
NV1295207Q00000X
FLOS18096207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100512121Medicaid
NVBE6079467OtherDEA
NV1295OtherMEDICAL LICENSE
NVCS14585OtherPHARMACY/CONTROLLED SUBSTANCE CERTIFICAE
NV1295OtherMEDICAL LICENSE
NVBE6079467OtherDEA