Provider Demographics
NPI:1013915289
Name:HACKER, TIMOTHY B (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:B
Last Name:HACKER
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 1:4640 W ALEXIS RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-1006
Mailing Address - Country:US
Mailing Address - Phone:419-843-8150
Mailing Address - Fax:419-479-2579
Practice Address - Street 1:4640 W ALEXIS RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-1006
Practice Address - Country:US
Practice Address - Phone:419-843-8150
Practice Address - Fax:419-479-2579
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35037540207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH04-02982OtherUHC
OH00153OtherPARAMOUNT
OH0639351OtherAETNA
OH000000141198OtherANTHEM
OH0375277Medicaid
OH000000141198OtherANTHEM
OH0639351OtherAETNA