Provider Demographics
NPI:1013919398
Name:BROTHERTON, TIMOTHY WAYNE (M,D,)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:WAYNE
Last Name:BROTHERTON
Suffix:
Gender:M
Credentials:M,D,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 EXECUTIVE DR
Mailing Address - Street 2:STE J
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-4155
Mailing Address - Country:US
Mailing Address - Phone:434-793-0044
Mailing Address - Fax:434-792-8864
Practice Address - Street 1:125 EXECUTIVE DR
Practice Address - Street 2:STE J
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-4155
Practice Address - Country:US
Practice Address - Phone:434-793-0044
Practice Address - Fax:434-792-8864
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101046457207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6060641Medicaid
VA6060641Medicaid
0307190001Medicare NSC
VA110003963Medicare PIN