Provider Demographics
NPI:1770636904
Name:NIVALA, TIMOTHY M
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:M
Last Name:NIVALA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5821 S SPRAGUE CT
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-6903
Mailing Address - Country:US
Mailing Address - Phone:253-396-4200
Mailing Address - Fax:
Practice Address - Street 1:5821 S SPRAGUE CT
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-6903
Practice Address - Country:US
Practice Address - Phone:253-396-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001854152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2014140Medicaid
WAG8872485Medicare PIN
WAG001051010Medicare PIN
WAGAB19069Medicare PIN
WAGAB19072Medicare PIN
WAU33537Medicare UPIN
WAGAB19070Medicare PIN
WAGAB19073Medicare PIN
WAG000135993Medicare PIN