Basic Information
Provider Information | |||||||||
NPI: | 1639150568 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRAY | ||||||||
FirstName: | TIMOTHY | ||||||||
MiddleName: | JAMES | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 555 N ARLINGTON AVE | ||||||||
Address2: |   | ||||||||
City: | RENO | ||||||||
State: | NV | ||||||||
PostalCode: | 895034723 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7757863040 | ||||||||
FaxNumber: | 7757861887 | ||||||||
Practice Location | |||||||||
Address1: | 555 N ARLINGTON AVE | ||||||||
Address2: |   | ||||||||
City: | RENO | ||||||||
State: | NV | ||||||||
PostalCode: | 895034723 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7757863040 | ||||||||
FaxNumber: | 7757885261 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/08/2005 | ||||||||
LastUpdateDate: | 12/20/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/20/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | A030821 | CA | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207X00000X | 5565 | NV | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207XX0801X | 5565 | NV | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma |
ID Information
ID | Type | State | Issuer | Description | 20-16657 | 05 | NV |   | MEDICAID | XPY075190 | 01 | CA | MEDI-CAL PIN | OTHER | 11050661 | 01 |   | CAQH | OTHER |