Provider Demographics
NPI:1508978115
Name:DODGE, TIMOTHY WARREN (MIT)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:WARREN
Last Name:DODGE
Suffix:
Gender:M
Credentials:MIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5127 STATE ROUTE 248
Mailing Address - Street 2:
Mailing Address - City:CANISTEO
Mailing Address - State:NY
Mailing Address - Zip Code:14823-9793
Mailing Address - Country:US
Mailing Address - Phone:607-698-4604
Mailing Address - Fax:
Practice Address - Street 1:76 VETERANS AVE
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:NY
Practice Address - Zip Code:14810-0810
Practice Address - Country:US
Practice Address - Phone:607-664-4615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246W00000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Cardiology