Provider Demographics
NPI:1679573034
Name:JESSIE, TIMOTHY ANTONIO (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:ANTONIO
Last Name:JESSIE
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 1:2121 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5100
Mailing Address - Country:US
Mailing Address - Phone:260-426-5431
Mailing Address - Fax:
Practice Address - Street 1:105 MILLS AVE STE 200
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4169
Practice Address - Country:US
Practice Address - Phone:505-426-3795
Practice Address - Fax:505-425-2653
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200501327208600000X
KS32580208600000X
OH35083403208600000X
MDD73747208600000X
NMMD2020-0191208600000X
IN01076415A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2501902Medicaid
NM69777233Medicaid
OH24-46612OtherUHC
OHP00144471OtherRRMC
OH2501902Medicaid