Provider Demographics
NPI:1770575649
Name:TIPPETT, TIMOTHY K (OD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:K
Last Name:TIPPETT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2465 WRIGHTSBORO RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-6244
Mailing Address - Country:US
Mailing Address - Phone:706-738-1102
Mailing Address - Fax:706-738-1149
Practice Address - Street 1:2465 WRIGHTSBORO RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-6244
Practice Address - Country:US
Practice Address - Phone:706-738-1102
Practice Address - Fax:706-738-1149
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-17
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA1296-T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00618549AMedicaid
GA41ZCCBBMedicare PIN
GAU34631Medicare UPIN
GA410046977Medicare PIN
GA00618549AMedicaid