Provider Demographics
NPI:1194813964
Name:O'CONNOR, TIMOTHY EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:EDWARD
Last Name:O'CONNOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:333 MAGAZINE ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-1867
Mailing Address - Country:US
Mailing Address - Phone:906-253-9374
Mailing Address - Fax:906-253-9002
Practice Address - Street 1:333 MAGAZINE ST
Practice Address - Street 2:SUITE 102
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-1867
Practice Address - Country:US
Practice Address - Phone:906-253-9374
Practice Address - Fax:906-253-9002
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301058216207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4249083Medicaid
MI4249083Medicaid
MI0N17980Medicare ID - Type Unspecified