Provider Demographics
NPI:1841321890
Name:TESLOW, TIMOTHY WALTER (MD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:WALTER
Last Name:TESLOW
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1275 SADLER WAY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-3175
Mailing Address - Country:US
Mailing Address - Phone:907-457-7874
Mailing Address - Fax:907-457-7060
Practice Address - Street 1:1275 SADLER WAY
Practice Address - Street 2:SUITE 102
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-3175
Practice Address - Country:US
Practice Address - Phone:907-457-7874
Practice Address - Fax:907-457-7060
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AK3579208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD17701Medicaid
AKMD17701Medicaid
AK151993Medicare PIN