Provider Demographics
NPI:1679161954
Name:STA MARIA, TIMOTHY GEORGE
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:GEORGE
Last Name:STA MARIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3763 RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-3827
Mailing Address - Country:US
Mailing Address - Phone:646-858-6212
Mailing Address - Fax:
Practice Address - Street 1:21914 MERRICK BLVD
Practice Address - Street 2:
Practice Address - City:LAURELTON
Practice Address - State:NY
Practice Address - Zip Code:11413-1923
Practice Address - Country:US
Practice Address - Phone:718-712-7895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY067552183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist