Provider Demographics
NPI:1962562348
Name:PELLETT, TIMOTHY KENT (OD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:KENT
Last Name:PELLETT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:778 BEAR CREEK DR
Mailing Address - Street 2:
Mailing Address - City:GULF SHORES
Mailing Address - State:AL
Mailing Address - Zip Code:36542
Mailing Address - Country:US
Mailing Address - Phone:251-967-2780
Mailing Address - Fax:
Practice Address - Street 1:2200 S MCKENZIE ST
Practice Address - Street 2:
Practice Address - City:FOLEY
Practice Address - State:AL
Practice Address - Zip Code:36535
Practice Address - Country:US
Practice Address - Phone:251-943-3369
Practice Address - Fax:251-943-3267
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS590TA277152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T69021Medicare UPIN
59850Medicare ID - Type Unspecified