Provider Demographics
NPI:1801885298
Name:BICKNELL, TIMOTHY D (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:D
Last Name:BICKNELL
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 1:104 PORTER DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05753-8527
Mailing Address - Country:US
Mailing Address - Phone:802-388-8808
Mailing Address - Fax:802-388-8322
Practice Address - Street 1:10 NORTH ST
Practice Address - Street 2:
Practice Address - City:VERGENNES
Practice Address - State:VT
Practice Address - Zip Code:05491-1107
Practice Address - Country:US
Practice Address - Phone:802-877-3466
Practice Address - Fax:802-877-1188
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042 0009191207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN1240Medicaid
VN1240Medicare ID - Type Unspecified
G15497Medicare UPIN