Provider Demographics
NPI:1508929209
Name:OBRIEN, TIMOTHY W
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:W
Last Name:OBRIEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HORSEHEADS
Mailing Address - State:NY
Mailing Address - Zip Code:14845
Mailing Address - Country:US
Mailing Address - Phone:607-739-2936
Mailing Address - Fax:607-734-8138
Practice Address - Street 1:227 HOFFMAN ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14905
Practice Address - Country:US
Practice Address - Phone:607-733-2141
Practice Address - Fax:607-734-8138
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY14000009087174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0809720001Medicare ID - Type Unspecified