Provider Demographics
NPI:1518928993
Name:WASSENAAR, TIMOTHY R (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:R
Last Name:WASSENAAR
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:N16W24131 RIVERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1106
Mailing Address - Country:US
Mailing Address - Phone:262-696-5690
Mailing Address - Fax:
Practice Address - Street 1:N16W24131 RIVERWOOD DR
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1106
Practice Address - Country:US
Practice Address - Phone:262-696-5690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI46327207R00000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34691700Medicaid
68375Medicare PIN
WI34691700Medicaid
I43433Medicare UPIN