Provider Demographics
NPI:1548231335
Name:MCNALLY, TIMOTHY G (DO)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:G
Last Name:MCNALLY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3364 S CENTER RD
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48519-1458
Mailing Address - Country:US
Mailing Address - Phone:810-743-3937
Mailing Address - Fax:810-743-9210
Practice Address - Street 1:3364 S CENTER RD
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48519-1458
Practice Address - Country:US
Practice Address - Phone:810-743-3937
Practice Address - Fax:810-743-9210
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5315110458207W00000X
MITMO12077207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5315110458OtherSTATE LICENSE
MI3391829Medicaid
MITM012077OtherSTATE LICENSE
MITM012077OtherSTATE LICENSE
MIG48259Medicare UPIN