Healthcare Provider Details

I. General information

NPI: 1366462046
Provider Name (Legal Business Name): TIMOTHY JAMES MULLALLY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 03/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11275 DELAWARE PKWY
CROWN POINT IN
46307-7812
US

IV. Provider business mailing address

PO BOX 108
CROWN POINT IN
46308-0108
US

V. Phone/Fax

Practice location:
  • Phone: 219-779-8735
  • Fax: 877-715-2312
Mailing address:
  • Phone: 219-779-8735
  • Fax: 877-715-2312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number02003099A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02003099A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: