Provider Demographics
NPI:1629097399
Name:HOOPER, TIMOTHY D
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:D
Last Name:HOOPER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:SONORA
Other - Middle Name:PRIMARY
Other - Last Name:CARE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:18701 TIFFENI DR
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:TWAIN HARTE
Mailing Address - State:CA
Mailing Address - Zip Code:95383-9406
Mailing Address - Country:US
Mailing Address - Phone:209-586-1400
Mailing Address - Fax:209-586-6748
Practice Address - Street 1:13951 MONO WAY
Practice Address - Street 2:STE A
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-4856
Practice Address - Country:US
Practice Address - Phone:209-532-3370
Practice Address - Fax:209-532-3340
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55188207Q00000X, 207QA0401X, 208D00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ20686ZMedicaid
CAZZZ20686ZMedicaid
CA00G551882Medicare PIN