Provider Demographics
NPI:1770506453
Name:O'BRIEN, TIMOTHY J (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:J
Last Name:O'BRIEN
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 1:2771 PARKE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926-7664
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 E MANITOBA AVE
Practice Address - Street 2:SUITE 109
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-3885
Practice Address - Country:US
Practice Address - Phone:509-925-6947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00021680174400000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7010614Medicaid
WA7010614Medicaid
WA000319179Medicare ID - Type Unspecified