Provider Demographics
NPI:1336131747
Name:MULDER, TIMOTHY S (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:S
Last Name:MULDER
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 1:502 2ND ST SW SUITE 1
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-3365
Mailing Address - Country:US
Mailing Address - Phone:320-235-7232
Mailing Address - Fax:320-231-8602
Practice Address - Street 1:502 2ND ST SW STE 1
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-3365
Practice Address - Country:US
Practice Address - Phone:320-235-7232
Practice Address - Fax:320-231-8602
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN40320207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN161218200Medicaid
MN161218200Medicaid
MN080012296Medicare ID - Type Unspecified