Basic Information
Provider Information | |||||||||
NPI: | 1164623476 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SAUNDERS | ||||||||
FirstName: | TIMOTHY | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1165 MONTGOMERY DR | ||||||||
Address2: |   | ||||||||
City: | SANTA ROSA | ||||||||
State: | CA | ||||||||
PostalCode: | 954054801 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7075463210 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1165 MONTGOMERY DR | ||||||||
Address2: |   | ||||||||
City: | SANTA ROSA | ||||||||
State: | CA | ||||||||
PostalCode: | 954054801 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7075463210 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/31/2007 | ||||||||
LastUpdateDate: | 03/26/2016 | ||||||||
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 | 207P00000X | M8977 | TX | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | A127711 | CA | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 204093302 | 05 | TX |   | MEDICAID | 204093301 | 05 | TX |   | MEDICAID | 8CA764 | 01 | TX | BCBSTX THRU SAEMA | OTHER | 204093304 | 05 | TX |   | MEDICAID | P00750613 | 01 | TX | RAILROAD MCARE THRU AEMA | OTHER | 204093303 | 05 | TX |   | MEDICAID | BP1-0026734 | 01 |   | INSTITUTIONAL PERMIT | OTHER |