Provider Demographics
NPI:1972561306
Name:HENNIE, TIMOTHY JAMES (OD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JAMES
Last Name:HENNIE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1910 JAKE ALEXANDER BLVD W
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28147-1162
Mailing Address - Country:US
Mailing Address - Phone:704-633-2581
Mailing Address - Fax:704-633-2592
Practice Address - Street 1:1910 JAKE ALEXANDER BLVD W
Practice Address - Street 2:SUITE 101
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28147-1163
Practice Address - Country:US
Practice Address - Phone:704-633-2581
Practice Address - Fax:704-633-2592
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1071152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC561430045OtherSUPERIOR VISION PLAN
NC2200141OtherUNITED HEALTHCARE
NC51812OtherDAVIS VISION PLAN
NC8909387Medicaid
NC110899OtherEYEMED
NC09387OtherBLUE CROSS BLUE SHIELD
NC10799OtherOPTICARE
NC48550OtherSPECTERA
NCNC01071OtherVISION BENEFITS OF AMERIC
NC561430045OtherPRIMARY PHYSICIAN CARE
NC561430045OtherPARTNERS
NC561430045OtherPARTNERS
NCT64929Medicare UPIN