Provider Demographics
NPI:1457597106
Name:TIMM, BRIAN GLENN (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:GLENN
Last Name:TIMM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 RIVERSIDE DR
Mailing Address - Street 2:SUITE M08
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-4176
Mailing Address - Country:US
Mailing Address - Phone:607-723-7454
Mailing Address - Fax:607-723-1567
Practice Address - Street 1:161 RIVERSIDE DR
Practice Address - Street 2:SUITE M08
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-4176
Practice Address - Country:US
Practice Address - Phone:607-723-7454
Practice Address - Fax:607-723-1567
Is Sole Proprietor?:No
Enumeration Date:2008-12-31
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYAN006710213ES0103X, 213ES0103X
FLPO 3367213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3608100Medicaid
J400220434Medicare UPIN