Provider Demographics
NPI:1871570416
Name:ST JOHN, TIMOTHY (DPM)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:ST JOHN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4310 LEONARD ST NW
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WALKER
Mailing Address - State:MI
Mailing Address - Zip Code:49534-8447
Mailing Address - Country:US
Mailing Address - Phone:616-453-6329
Mailing Address - Fax:616-453-1725
Practice Address - Street 1:3179 W HOUGHTON LAKE DR
Practice Address - Street 2:
Practice Address - City:HOUGHTON LAKE
Practice Address - State:MI
Practice Address - Zip Code:48629-9256
Practice Address - Country:US
Practice Address - Phone:989-366-8332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-24
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITS001531213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3119585Medicaid
MI5725001Medicare ID - Type Unspecified
MIU08311Medicare UPIN
MI3119585Medicaid