Healthcare Provider Details

I. General information

NPI: 1497869853
Provider Name (Legal Business Name): TIMOTHY MCGILLIVRAY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23451 MADISON ST SUITE 340
TORRANCE CA
90505-4763
US

IV. Provider business mailing address

23451 MADISON ST SUITE 340
TORRANCE CA
90505-4763
US

V. Phone/Fax

Practice location:
  • Phone: 310-373-6864
  • Fax: 310-791-8326
Mailing address:
  • Phone: 310-373-6864
  • Fax: 310-791-8326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG73656
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: