Healthcare Provider Details

I. General information

NPI: 1962670307
Provider Name (Legal Business Name): TIMOTHY D MIESMER ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2008
Last Update Date: 03/18/2020
Certification Date: 03/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 N WOODLAND BLVD UNIT 8317
DELAND FL
32723-8418
US

IV. Provider business mailing address

6048 LAUREN LN
RICHMOND KY
40475-6702
US

V. Phone/Fax

Practice location:
  • Phone: 859-248-5467
  • Fax:
Mailing address:
  • Phone: 859-248-5467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberAT1210
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL5565
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: