Provider Demographics
NPI:1255342978
Name:VANEVERY, TIMOTHY (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:VANEVERY
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 1:2061 M 119
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-8914
Mailing Address - Country:US
Mailing Address - Phone:231-487-2020
Mailing Address - Fax:231-487-6166
Practice Address - Street 1:2061 M 119
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8914
Practice Address - Country:US
Practice Address - Phone:231-487-2020
Practice Address - Fax:231-487-6166
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITV039837207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1802400101OtherBLUE CROSS BLUE SHIELD
MI7000020101OtherPRIORITY HEALTH
MI7000020101OtherPRIORITY HEALTH
MIN89920001Medicare ID - Type Unspecified