Basic Information
Provider Information | |||||||||
NPI: | 1285081711 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | O'CONNOR | ||||||||
FirstName: | TIMOTHY | ||||||||
MiddleName: | J | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | O'CONNOR | ||||||||
OtherFirstName: | TIMOTHY | ||||||||
OtherMiddleName: | J | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: | III | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 5003 S MIAMI BLVD STE 300 | ||||||||
Address2: |   | ||||||||
City: | DURHAM | ||||||||
State: | NC | ||||||||
PostalCode: | 277038589 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9193540840 | ||||||||
FaxNumber: | 8778406694 | ||||||||
Practice Location | |||||||||
Address1: | 4220 APEX HWY STE 200 | ||||||||
Address2: |   | ||||||||
City: | DURHAM | ||||||||
State: | NC | ||||||||
PostalCode: | 277135295 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9193540840 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/13/2016 | ||||||||
LastUpdateDate: | 08/26/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/26/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 2084P0800X | 2020-03627 | NC | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.