Healthcare Provider Details

I. General information

NPI: 1366437402
Provider Name (Legal Business Name): TIMOTHY HOLLISTER JONES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 12/30/2022
Certification Date: 12/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6621 BAY LAUREL PL STE A
AVILA BEACH CA
93424-3504
US

IV. Provider business mailing address

PO BOX 159
AVILA BEACH CA
93424-0159
US

V. Phone/Fax

Practice location:
  • Phone: 805-556-7006
  • Fax: 805-439-1482
Mailing address:
  • Phone: 805-556-7006
  • Fax: 805-439-1482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA55265
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: