Provider Demographics
NPI:1134626070
Name:OVERTON, TIMOTHY WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:WILLIAM
Last Name:OVERTON
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 1:117 CAMINO DE VIDA STE 300
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:NM
Mailing Address - Zip Code:88435-2267
Mailing Address - Country:US
Mailing Address - Phone:575-472-4311
Mailing Address - Fax:877-651-0289
Practice Address - Street 1:117 CAMINO DE VIDA STE 300
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:NM
Practice Address - Zip Code:88435-2267
Practice Address - Country:US
Practice Address - Phone:575-472-4311
Practice Address - Fax:877-651-0289
Is Sole Proprietor?:No
Enumeration Date:2018-04-08
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM390200000X
NMMD2021-0264207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program