MEDICARE: DR. TIMOTHY D ROOT M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	000487	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033322078
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TIMOTHY D ROOT M.D.

Provider Business Mailing Address
First Line	:	345 N CLYDE MORRIS BLVD
Second Line	:	SUITE 330
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-3114
Country	:	US
Telephone Number	:	386-672-4244
Fax Number	:

Provider Business Practice Location Address
First Line	:	345 N CLYDE MORRIS BLVD
Second Line	:	SUITE 330
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-3114
Country	:	US
Telephone Number	:	386-672-4244
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/07/2007
Last Update Date	:	06/07/2012

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