Provider Demographics
NPI:1619922879
Name:QUILLEN, TIMOTHY JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:JOSEPH
Last Name:QUILLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:MANAGED CARE DEPT
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:394 SINGLETON RIDGE RD
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-9150
Practice Address - Country:US
Practice Address - Phone:843-347-8765
Practice Address - Fax:843-347-3499
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC14869208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC774449OtherWELLCARE
SC80023042OtherSELECT HEALTH
SCP00360562OtherRAILROAD MEDICARE
NC890585WMedicaid
SCGP4522Medicaid
SCP00360562OtherRAILROAD MEDICARE