Provider Demographics
NPI:1609803758
Name:OBRIEN, TIMOTHY JOHN (CPO)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:JOHN
Last Name:OBRIEN
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MERCADO ST
Mailing Address - Street 2:203
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-7300
Mailing Address - Country:US
Mailing Address - Phone:970-259-9258
Mailing Address - Fax:970-385-7262
Practice Address - Street 1:1 MERCADO ST
Practice Address - Street 2:203
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7300
Practice Address - Country:US
Practice Address - Phone:970-259-9258
Practice Address - Fax:970-385-7262
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1428222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Not Answered224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08002149Medicaid
CO08002149Medicaid