Basic Information
| Provider Information | |||||||||
| NPI: | 1063961654 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOCK | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | GLENN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8808 N INDIAN TRAIL RD | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992089126 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4815 N ASSEMBLY ST | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992056185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094347000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2016 | ||||||||
| LastUpdateDate: | 09/24/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 60677430 | WA | Y | Eye and Vision Services Providers | Optometrist | 152W00000X | 100382 | ID | N | Eye and Vision Services Providers | Optometrist |
No ID Information.