Provider Demographics
NPI:1639136823
Name:O'BRIEN, TIMOTHY D (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:D
Last Name:O'BRIEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 228
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:OH
Mailing Address - Zip Code:43138-0228
Mailing Address - Country:US
Mailing Address - Phone:740-380-1300
Mailing Address - Fax:
Practice Address - Street 1:819 STATE ROUTE 664 N STE B
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:OH
Practice Address - Zip Code:43138-8540
Practice Address - Country:US
Practice Address - Phone:740-380-8140
Practice Address - Fax:740-380-8150
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35076169208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2272964Medicaid
OHF56709Medicare UPIN
OH2272964Medicaid