Basic Information
| Provider Information | |||||||||
| NPI: | 1093789752 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WESTGATE | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | O. D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 885 S GOVERNORS AVE | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199044158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3027345861 | ||||||||
| FaxNumber: | 3027341921 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 BRIDGEVILLE HWY | ||||||||
| Address2: | |||||||||
| City: | SEAFORD | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199731616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026299197 | ||||||||
| FaxNumber: | 3026293335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 02/27/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 130001190 | DE | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | G00016 | 01 | MEDICARE GROUP PIN | OTHER | I3-0001190 | 01 | DE | LICENSE | OTHER | 000A74H16 | 01 | MEDICARE PTAN | OTHER | 11220847 | 01 | CAQH | OTHER | 1245251313 | 01 | MEDICARE GROUP NPI | OTHER | 000214822 | 05 | DE | MEDICAID |