Provider Demographics
NPI:1861518789
Name:TODD, TIMOTHY L (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:L
Last Name:TODD
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:PO BOX 165
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49501-0165
Mailing Address - Country:US
Mailing Address - Phone:616-455-5000
Mailing Address - Fax:
Practice Address - Street 1:3225 N EVERGREEN DR NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9334
Practice Address - Country:US
Practice Address - Phone:616-364-1500
Practice Address - Fax:616-364-6400
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010961652084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHTO4070222Medicare PIN
OHT04070225Medicare PIN
OHT04070227Medicare PIN
OHT04070228Medicare PIN
OHT04070226Medicare PIN
MID16083146Medicare PIN
OHT04070224Medicare PIN
OHH32408Medicare UPIN