Provider Demographics
NPI:1831308840
Name:KRESOWIK, TIMOTHY P (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:P
Last Name:KRESOWIK
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 1:3319 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-2125
Mailing Address - Country:US
Mailing Address - Phone:563-359-1641
Mailing Address - Fax:563-359-4634
Practice Address - Street 1:3319 SPRING ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-2125
Practice Address - Country:US
Practice Address - Phone:563-359-1641
Practice Address - Fax:563-359-4634
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA40027208800000X
IAR-7811208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA07364OtherBLUE CROSS BLUE SHIELD
IL91338OtherBLUE CROSS BLUE SHIELD
IA0904060Medicaid
IA0073643Medicaid
IL91338OtherBLUE CROSS BLUE SHIELD
IA0073643Medicaid
IA0184500001Medicare NSC
IACH6425Medicare PIN
IACP7499Medicare PIN