Provider Demographics
NPI:1720172844
Name:KINGSBURY, TIMOTHY (DO)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:KINGSBURY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:KITTERY
Mailing Address - State:ME
Mailing Address - Zip Code:03904-0189
Mailing Address - Country:US
Mailing Address - Phone:207-439-9924
Mailing Address - Fax:
Practice Address - Street 1:111 ROGERS RD
Practice Address - Street 2:
Practice Address - City:KITTERY
Practice Address - State:ME
Practice Address - Zip Code:03904-1453
Practice Address - Country:US
Practice Address - Phone:207-439-9924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1254204D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30002502Medicaid
NH30002502Medicaid
MM1151Medicare ID - Type Unspecified