Provider Demographics
NPI:1871644864
Name:MASTERS, TIMOTHY TODD (OD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:TODD
Last Name:MASTERS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 CLOVER LANE
Mailing Address - Street 2:
Mailing Address - City:STORM LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:50588-2702
Mailing Address - Country:US
Mailing Address - Phone:712-732-7068
Mailing Address - Fax:
Practice Address - Street 1:100 EAST MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:STORM LAKE
Practice Address - State:IA
Practice Address - Zip Code:50588-1873
Practice Address - Country:US
Practice Address - Phone:712-732-7624
Practice Address - Fax:712-732-7627
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01849152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2245720Medicaid
IA51285Medicare ID - Type Unspecified
T01396Medicare UPIN