Basic Information
| Provider Information | |||||||||
| NPI: | 1912127424 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TIMOTHY | ||||||||
| FirstName: | PROMILA | ||||||||
| MiddleName: | K. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TUDU | ||||||||
| OtherFirstName: | PROMILA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3301 STANLEY ST | ||||||||
| Address2: | |||||||||
| City: | STEVENS POINT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544811323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153417332 | ||||||||
| FaxNumber: | 7018578056 | ||||||||
| Practice Location | |||||||||
| Address1: | 3301 STANLEY ST | ||||||||
| Address2: | |||||||||
| City: | STEVENS POINT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544811323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153417332 | ||||||||
| FaxNumber: | 7018578056 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2007 | ||||||||
| LastUpdateDate: | 10/26/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 14108 | ND | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 67961 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1468854 | 05 | ND | MEDICAID |