Healthcare Provider Details

I. General information

NPI: 1124552658
Provider Name (Legal Business Name): TIMOTHY MATTHEW MAHANES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2017
Last Update Date: 11/03/2023
Certification Date: 11/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 DOLBEER ST
EUREKA CA
95501-4736
US

IV. Provider business mailing address

4877 ALLEN CT
EUREKA CA
95503-5901
US

V. Phone/Fax

Practice location:
  • Phone: 707-445-8121
  • Fax:
Mailing address:
  • Phone: 859-351-6202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA183482
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: