Healthcare Provider Details

I. General information

NPI: 1346232253
Provider Name (Legal Business Name): TIMOTHY MICHAEL REESE O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date: 03/23/2006
Reactivation Date: 04/04/2006

III. Provider practice location address

1180 VILLAGE RIDGE PT
MONUMENT CO
80132-8992
US

IV. Provider business mailing address

1180 VILLAGE RIDGE PT
MONUMENT CO
80132-8992
US

V. Phone/Fax

Practice location:
  • Phone: 719-488-9595
  • Fax: 719-488-8383
Mailing address:
  • Phone: 719-488-9595
  • Fax: 719-488-8383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1625
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: