Provider Demographics
NPI:1063561322
Name:KAUFMAN, TIMOTHY WAYNE (DC)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:WAYNE
Last Name:KAUFMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1279 NORTH FORREST DRIVE
Mailing Address - Street 2:
Mailing Address - City:METAMORA
Mailing Address - State:IL
Mailing Address - Zip Code:61548-9439
Mailing Address - Country:US
Mailing Address - Phone:309-256-1501
Mailing Address - Fax:
Practice Address - Street 1:387 OLD GERMANTOWN RD
Practice Address - Street 2:
Practice Address - City:METAMORA
Practice Address - State:IL
Practice Address - Zip Code:61548-8679
Practice Address - Country:US
Practice Address - Phone:309-383-2772
Practice Address - Fax:309-383-2773
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL10232005OtherBCBS
IL54723Medicare UPIN
IL10232005OtherBCBS