Provider Demographics
NPI:1689661761
Name:KWIATKOWSKI, TIMOTHY (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:KWIATKOWSKI
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 1:3114 CROASDAILE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-2508
Mailing Address - Country:US
Mailing Address - Phone:919-425-1565
Mailing Address - Fax:919-425-0478
Practice Address - Street 1:566 RUIN CREEK RD
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-2927
Practice Address - Country:US
Practice Address - Phone:252-436-1162
Practice Address - Fax:919-425-0478
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9701443207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8911908Medicaid
NC8911908Medicaid
NC2258355FMedicare PIN