Provider Demographics
NPI:1639179930
Name:BOLLOM, TIMOTHY S (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:S
Last Name:BOLLOM
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 1:2200 NE NEFF RD
Mailing Address - Street 2:STE 200
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4283
Mailing Address - Country:US
Mailing Address - Phone:541-382-3344
Mailing Address - Fax:541-382-1681
Practice Address - Street 1:2200 NE NEFF RD
Practice Address - Street 2:STE 200
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4283
Practice Address - Country:US
Practice Address - Phone:541-382-3344
Practice Address - Fax:541-382-1681
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD25128207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORMD25128OtherOBME
OR233192Medicaid
I00295Medicare UPIN
ORMD25128OtherOBME