Provider Demographics
NPI:1043464639
Name:DO, TIMOTHY DERRICK (MD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:DERRICK
Last Name:DO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:4689 US HIGHWAY 17
Mailing Address - Street 2:SUITE 11
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32003-4831
Mailing Address - Country:US
Mailing Address - Phone:904-269-7007
Mailing Address - Fax:866-264-0529
Practice Address - Street 1:4689 US HIGHWAY 17
Practice Address - Street 2:SUITE 11
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32003-4831
Practice Address - Country:US
Practice Address - Phone:904-269-7007
Practice Address - Fax:866-264-0529
Is Sole Proprietor?:No
Enumeration Date:2008-11-09
Last Update Date:2022-01-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
DC150583207T00000X
FLME111835207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009327000Medicaid
FLHH873YMedicare PIN