Provider Demographics
NPI:1548286248
Name:PANGBORN, TIMOTHY R (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:R
Last Name:PANGBORN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 W CEDAR ST
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32502-4910
Mailing Address - Country:US
Mailing Address - Phone:800-444-7009
Mailing Address - Fax:818-587-2493
Practice Address - Street 1:800 E WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-8359
Practice Address - Country:US
Practice Address - Phone:707-464-8511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG39084207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G390840OtherBLUE SHIELD
CA00G390840Medicaid
CA00G390840Medicaid
CA00G390840Medicare ID - Type Unspecified