Provider Demographics
NPI:1891716478
Name:MOONEY, TIMOTHY M (DPM)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:M
Last Name:MOONEY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3046
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-0746
Mailing Address - Country:US
Mailing Address - Phone:775-356-4888
Mailing Address - Fax:
Practice Address - Street 1:2385 E PRATER WAY
Practice Address - Street 2:SUITE 205
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89434-9629
Practice Address - Country:US
Practice Address - Phone:775-356-4888
Practice Address - Fax:775-356-4890
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0008213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1891716478Medicaid
11041250OtherCAQH
1891716478OtherNPI
11041250OtherCAQH