Healthcare Provider Details

I. General information

NPI: 1407060387
Provider Name (Legal Business Name): TIMOTHY HIGGINS RD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 01/20/2020
Certification Date: 01/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11110 MEDICAL CAMPUS RD STE 108
HAGERSTOWN MD
21742-6734
US

IV. Provider business mailing address

19133 CHERRY TREE DR
HAGERSTOWN MD
21742-2826
US

V. Phone/Fax

Practice location:
  • Phone: 301-714-4041
  • Fax: 301-714-4351
Mailing address:
  • Phone: 301-714-4041
  • Fax: 301-714-4351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberD02116
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: