Provider Demographics
NPI:1831385749
Name:BORK, TIMOTHY DOUGLAS (IDC)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:DOUGLAS
Last Name:BORK
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 836 BOX 512
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09636-0500
Mailing Address - Country:US
Mailing Address - Phone:0113909-556-2854
Mailing Address - Fax:0113909-556-6291
Practice Address - Street 1:PSC 836 BOX 512
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09636-0500
Practice Address - Country:US
Practice Address - Phone:0113909-556-2854
Practice Address - Fax:0113909-556-6291
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-25
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman