Healthcare Provider Details

I. General information

NPI: 1780752469
Provider Name (Legal Business Name): TIMOTHY JAMES MUHONEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 MCKENNA DR
MOUNTAIN HOME ID
83647
US

IV. Provider business mailing address

495 E 17TH N
MOUNTAIN HOME ID
83647-1757
US

V. Phone/Fax

Practice location:
  • Phone: 208-587-9703
  • Fax:
Mailing address:
  • Phone: 505-801-6577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberNM2007-0097
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number40961
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD186714
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00043473
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-11354
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: