Provider Demographics
NPI:1912127424
Name:TIMOTHY, PROMILA K (MD)
Entity Type:Individual
Prefix:DR
First Name:PROMILA
Middle Name:K
Last Name:TIMOTHY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PROMILA
Other - Middle Name:
Other - Last Name:TUDU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3301 STANLEY ST
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54481-1323
Mailing Address - Country:US
Mailing Address - Phone:715-341-7332
Mailing Address - Fax:701-857-8056
Practice Address - Street 1:3301 STANLEY ST
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481-1323
Practice Address - Country:US
Practice Address - Phone:715-341-7332
Practice Address - Fax:701-857-8056
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND14108207Q00000X
WI67961207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1468854Medicaid
NDN723190Medicare PIN
MI238646OtherRHC MEDICARE
MI0070029OtherBCBS OF MI
MI1912127424Medicaid