Provider Demographics
NPI:1215908553
Name:BURKE, TIMOTHY WILLIAM (DO)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:WILLIAM
Last Name:BURKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15775 SE 82ND DR
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-8551
Mailing Address - Country:US
Mailing Address - Phone:503-722-9155
Mailing Address - Fax:503-722-0420
Practice Address - Street 1:15775 SE 82ND DR
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-8551
Practice Address - Country:US
Practice Address - Phone:503-722-9155
Practice Address - Fax:503-722-0420
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO13104207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR279208Medicaid
OR121425Medicare ID - Type Unspecified
OR279208Medicaid