Provider Demographics
NPI:1568523389
Name:HUBBARD, TIMOTHY MICHAEL (DO)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:MICHAEL
Last Name:HUBBARD
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 1:4400 SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-5747
Mailing Address - Country:US
Mailing Address - Phone:262-652-5454
Mailing Address - Fax:262-652-5732
Practice Address - Street 1:4400 SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-5747
Practice Address - Country:US
Practice Address - Phone:262-652-5454
Practice Address - Fax:262-652-5732
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27225207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI300240000Medicaid
WI80-065Medicare ID - Type Unspecified
WI300240000Medicaid