Provider Demographics
NPI:1679572952
Name:OLDFATHER, TIMOTHY (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:OLDFATHER
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 1:82 PUUHONU PL
Mailing Address - Street 2:SUITE 202
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-2010
Mailing Address - Country:US
Mailing Address - Phone:808-933-3040
Mailing Address - Fax:808-933-3075
Practice Address - Street 1:82 PUUHONU PL
Practice Address - Street 2:SUITE 202
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-2010
Practice Address - Country:US
Practice Address - Phone:808-933-3040
Practice Address - Fax:808-933-3075
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD3343208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIC43079OtherHMSA PROVIDER NUMBER
HI03925801Medicaid
HIH0000BDWFLMedicare ID - Type UnspecifiedPROVIDER NUMBER
HIC97553Medicare UPIN