Provider Demographics
NPI:1902049463
Name:BICKERTON, TIMOTHY MICHAEL (IDC)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:MICHAEL
Last Name:BICKERTON
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 1:599 HERBERT ST
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-6418
Mailing Address - Country:US
Mailing Address - Phone:619-708-7805
Mailing Address - Fax:
Practice Address - Street 1:USS GEORGE WASHINGTON CVN 73
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96650-2801
Practice Address - Country:US
Practice Address - Phone:0118146-816-7382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-14
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman