Provider Demographics
NPI:1194732529
Name:PELFREY, TIMOTHY MAXWELL (MD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:MAXWELL
Last Name:PELFREY
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 1:13827 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-9019
Mailing Address - Country:US
Mailing Address - Phone:937-644-0102
Mailing Address - Fax:
Practice Address - Street 1:498 LONDON AVE
Practice Address - Street 2:SUITE B
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-5512
Practice Address - Country:US
Practice Address - Phone:937-642-0046
Practice Address - Fax:937-642-2012
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35 . 047727208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0594763Medicaid
OHPE0569442Medicare ID - Type Unspecified
OHA16129Medicare UPIN