Provider Demographics
NPI:1790750115
Name:MCNICOLL, TIMOTHY J (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:J
Last Name:MCNICOLL
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 1:89 HUMBOLDT ST
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-5359
Mailing Address - Country:US
Mailing Address - Phone:805-391-7722
Mailing Address - Fax:805-526-1443
Practice Address - Street 1:1180 NEWFIELD AVE
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-1409
Practice Address - Country:US
Practice Address - Phone:314-888-5233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG48100207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G481000Medicaid
CAE89826Medicare UPIN
CA00G481000Medicaid