Provider Demographics
NPI:1669451951
Name:POLK, TIMOTHY DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DANIEL
Last Name:POLK
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 1:6115 FALLS RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-2219
Mailing Address - Country:US
Mailing Address - Phone:410-377-7611
Mailing Address - Fax:410-377-8221
Practice Address - Street 1:6115 FALLS RD
Practice Address - Street 2:SUITE 300
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-2219
Practice Address - Country:US
Practice Address - Phone:410-377-7611
Practice Address - Fax:410-377-8221
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0051788207W00000X
PAMD438329207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD141936ZACZMedicare PIN
PA169150N2EMedicare PIN
S71918JJMedicare ID - Type UnspecifiedPERSONAL MEDICARE NO.
G05300Medicare UPIN