Healthcare Provider Details

I. General information

NPI: 1710015318
Provider Name (Legal Business Name): DAVID ALAN TIMM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 12/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1806 CARTER ST
VIDALIA LA
71373-3115
US

IV. Provider business mailing address

1806 CARTER ST
VIDALIA LA
71373-3115
US

V. Phone/Fax

Practice location:
  • Phone: 318-336-7172
  • Fax: 318-336-7176
Mailing address:
  • Phone: 318-336-7172
  • Fax: 318-336-7176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPO4933
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPO4870
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD016299
License Number StateLA
# 4
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number016299
License Number StateLA

VIII. Authorized Official

Name: DR. DAVID ALAN TIMM
Title or Position: OWNER
Credential: MD
Phone: 601-442-7676