Provider Demographics
NPI:1881649333
Name:TIMMERMAN, MARK G (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:G
Last Name:TIMMERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:436 SUNRISE DR
Mailing Address - Street 2:
Mailing Address - City:SPRING GREEN
Mailing Address - State:WI
Mailing Address - Zip Code:53588-9286
Mailing Address - Country:US
Mailing Address - Phone:608-588-2502
Mailing Address - Fax:608-588-7724
Practice Address - Street 1:436 SUNRISE DR
Practice Address - Street 2:
Practice Address - City:SPRING GREEN
Practice Address - State:WI
Practice Address - Zip Code:53588-9286
Practice Address - Country:US
Practice Address - Phone:608-588-2502
Practice Address - Fax:608-588-7724
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31402-020207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31648300Medicaid
WIP00463755OtherRAILROAD MEDICARE
002557065Medicare Oscar/Certification
002557065Medicare PIN
WI31648300Medicaid