Provider Demographics
NPI:1639218662
Name:YAZZIE, TIMOTHY (DO)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:YAZZIE
Suffix:
Gender:M
Credentials:DO
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 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-375-1770
Mailing Address - Fax:
Practice Address - Street 1:1134 N 500 W
Practice Address - Street 2:SUITE 102
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3383
Practice Address - Country:US
Practice Address - Phone:801-357-1770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM18-2006207Q00000X
UT331777-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO33732361Medicaid
NM04452755Medicaid
AZ253562Medicaid
320059Medicare Oscar/Certification
8HG769Medicare PIN