Provider Demographics
NPI:1902124100
Name:SMITH, TIMOTHY RYAN (MD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:RYAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:420 DELAWARE ST SE
Mailing Address - Street 2:MMC 391
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0341
Mailing Address - Country:US
Mailing Address - Phone:612-624-1192
Mailing Address - Fax:612-626-7042
Practice Address - Street 1:420 DELAWARE ST SE
Practice Address - Street 2:MMC 391
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0341
Practice Address - Country:US
Practice Address - Phone:612-624-1192
Practice Address - Fax:612-626-7042
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS04-36610208000000X
MN54769208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics