Provider Demographics
NPI:1659433712
Name:LONGACRE, TIMOTHY LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:LEE
Last Name:LONGACRE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:13018 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154-1091
Mailing Address - Country:US
Mailing Address - Phone:402-359-4410
Mailing Address - Fax:402-452-3018
Practice Address - Street 1:2501 CAPEHART RD
Practice Address - Street 2:
Practice Address - City:OFFUTT AFB
Practice Address - State:NE
Practice Address - Zip Code:68113-1043
Practice Address - Country:US
Practice Address - Phone:402-591-4503
Practice Address - Fax:402-591-4519
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE17200207Q00000X, 208D00000X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology