Provider Demographics
NPI:1962629824
Name:TIMOTHY A VAN DYNE DPM INC
Entity Type:Organization
Organization Name:TIMOTHY A VAN DYNE DPM INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:VAN DYNE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:559-435-0261
Mailing Address - Street 1:5777 N FRESNO ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-6065
Mailing Address - Country:US
Mailing Address - Phone:559-435-0261
Mailing Address - Fax:
Practice Address - Street 1:5777 N FRESNO ST
Practice Address - Street 2:SUITE 102
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-6065
Practice Address - Country:US
Practice Address - Phone:559-435-0261
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2025261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE2025OtherMEDICARE ID 000E20250