Healthcare Provider Details

I. General information

NPI: 1134495054
Provider Name (Legal Business Name): TIMOTHY JOHN PARTRIDGE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2012
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 S SAN FRANCISCO ST
FLAGSTAFF AZ
86011-0001
US

IV. Provider business mailing address

824 S SAN FRANCISCO ST
FLAGSTAFF AZ
86011-0001
US

V. Phone/Fax

Practice location:
  • Phone: 928-523-2131
  • Fax:
Mailing address:
  • Phone: 928-523-2131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number042.0013502
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number62878
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: