Healthcare Provider Details

I. General information

NPI: 1841759842
Provider Name (Legal Business Name): TIMOTHY YAOPRUKE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 03/31/2022
Certification Date: 03/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N PEPPER AVE
COLTON CA
92324-1801
US

IV. Provider business mailing address

13458 CHRISTIAN BARRETT DR
MOORPARK CA
93021-2881
US

V. Phone/Fax

Practice location:
  • Phone: 909-580-1000
  • Fax:
Mailing address:
  • Phone: 805-990-0614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberPTL1213
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: