Provider Demographics
NPI:1700992294
Name:O'LEARY, TIMOTHY R (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:R
Last Name:O'LEARY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:11475 OLDE CABIN RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7129
Mailing Address - Country:US
Mailing Address - Phone:314-991-8210
Mailing Address - Fax:314-991-8206
Practice Address - Street 1:1350 US HIGHWAY 61
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-4124
Practice Address - Country:US
Practice Address - Phone:636-933-0303
Practice Address - Fax:636-933-0293
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO1021872085R0001X
IL0360952082085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204995302Medicaid
329705OtherHEALTHLINK
270330OtherMEDICARE COMPLETE
270330OtherUHC
27716OtherGROUP HEALTH PLAN
MOF51287OtherMERCY HEALTH PLANS
3848OtherCMR
MO194361OtherMISSOURI BLUE SHIELD
27716OtherGROUP HEALTH PLAN