Provider Demographics
NPI:1720181068
Name:STALLMAN, TIMOTHY J
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:J
Last Name:STALLMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:TIMOTHY
Other - Middle Name:J
Other - Last Name:STALLMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:2280 MAPLE POINT RD
Mailing Address - Street 2:
Mailing Address - City:PICKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49719
Mailing Address - Country:US
Mailing Address - Phone:906-647-6115
Mailing Address - Fax:
Practice Address - Street 1:16523 S WATERTOWER DR
Practice Address - Street 2:
Practice Address - City:KINCHELOE
Practice Address - State:MI
Practice Address - Zip Code:49719
Practice Address - Country:US
Practice Address - Phone:906-495-3030
Practice Address - Fax:906-495-3035
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009145207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIVAD000Medicare UPIN