Healthcare Provider Details

I. General information

NPI: 1760477368
Provider Name (Legal Business Name): TIMOTHY JOSEPH FLOCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 06/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 WARNER DR
LEWISTON ID
83501
US

IV. Provider business mailing address

320 WARNER DR
LEWISTON ID
83501
US

V. Phone/Fax

Practice location:
  • Phone: 208-743-3523
  • Fax: 208-746-8741
Mailing address:
  • Phone: 208-743-3523
  • Fax: 208-746-8741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License NumberMD00032793
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License NumberM6831
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: