Provider Demographics
NPI:1730163023
Name:GAMMONS, TIMOTHY (DO)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:
Last Name:GAMMONS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4845 E 14 MILE RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-6442
Mailing Address - Country:US
Mailing Address - Phone:586-977-5780
Mailing Address - Fax:586-977-0391
Practice Address - Street 1:4845 E 14 MILE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-6442
Practice Address - Country:US
Practice Address - Phone:586-977-5780
Practice Address - Fax:586-977-0391
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013821207QA0401X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI133449OtherCARE-PREFERRED CHOICES
MI1730163023Medicaid
MIH53730OtherHAP
MI700H217350OtherBLUE SHIELD
MIH53730OtherHAP
MIH53730Medicare UPIN
MI1730163023Medicaid