Provider Demographics
NPI:1457394207
Name:DAHLGREN, TIMOTHY JON (MD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:JON
Last Name:DAHLGREN
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:PO BOX 11539
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92685-1539
Mailing Address - Country:US
Mailing Address - Phone:866-899-2586
Mailing Address - Fax:
Practice Address - Street 1:2520 CHERRY AVE
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-4229
Practice Address - Country:US
Practice Address - Phone:360-792-6710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00028201207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8125130Medicaid
WA8861275Medicare PIN
WA8801042Medicare ID - Type Unspecified
WAE99269Medicare UPIN