Provider Demographics
NPI:1720152002
Name:CHEN, TIMOTHY M (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:M
Last Name:CHEN
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 1:2655 1ST ST STE 360
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-1547
Mailing Address - Country:US
Mailing Address - Phone:805-583-7640
Mailing Address - Fax:
Practice Address - Street 1:2655 1ST ST STE 360
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1547
Practice Address - Country:US
Practice Address - Phone:805-583-7640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA89234207Q00000X
WI45690-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A892340Medicaid
H89375Medicare UPIN
WI543751136Medicare PIN
00A892340Medicare ID - Type Unspecified
CA00A892340Medicaid