Provider Demographics
NPI:1790731743
Name:CORGAN, TIMOTHY (OD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:
Last Name:CORGAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:TIMOTHY
Other - Middle Name:
Other - Last Name:CORGAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:1400 UNIVERSITY DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-5105
Mailing Address - Country:US
Mailing Address - Phone:715-732-4181
Mailing Address - Fax:
Practice Address - Street 1:1400 UNIVERSITY DR
Practice Address - Street 2:SUITE 101
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-5105
Practice Address - Country:US
Practice Address - Phone:715-732-4181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2655-035152W00000X
MI4901003841152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38597500Medicaid
WI38597500Medicaid
WIU62534Medicare UPIN