Provider Demographics
NPI:1124149653
Name:RILEY, TIMOTHY B (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:B
Last Name:RILEY
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 1:4045 3RD AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2132
Mailing Address - Country:US
Mailing Address - Phone:619-297-4901
Mailing Address - Fax:619-688-5993
Practice Address - Street 1:4045 3RD AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2132
Practice Address - Country:US
Practice Address - Phone:619-297-4901
Practice Address - Fax:619-688-5993
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG33037207V00000X, 207VG0400X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ57305ZOtherBLUE SHIELD OF CA
CAG33037Medicare ID - Type Unspecified
CAZZZ57305ZOtherBLUE SHIELD OF CA