Provider Demographics
NPI:1316968985
Name:GENDRON, TIMOTHY LOUIS (MD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:LOUIS
Last Name:GENDRON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4240 PARK GLEN RD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-5427
Mailing Address - Country:US
Mailing Address - Phone:612-925-6033
Mailing Address - Fax:612-925-8496
Practice Address - Street 1:149 THOMPSON AVE E STE 150
Practice Address - Street 2:
Practice Address - City:WEST ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-3238
Practice Address - Country:US
Practice Address - Phone:651-450-0860
Practice Address - Fax:651-450-0759
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD100472084P0800X
MA2051002084P0805X
MN560582084P0800X
WI69137-202084P0800X
CAC1732292084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAGEA31209Medicare Oscar/Certification
MAG99570Medicare UPIN
MA3207145Medicaid