Healthcare Provider Details

I. General information

NPI: 1063401578
Provider Name (Legal Business Name): TIMOTHY W TOLFORD OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 01/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 CONGRESS ST
PORTLAND ME
04102-3323
US

IV. Provider business mailing address

PO BOX 7487
PORTLAND ME
04112-7487
US

V. Phone/Fax

Practice location:
  • Phone: 207-772-8384
  • Fax: 207-773-0020
Mailing address:
  • Phone: 207-885-8686
  • Fax: 207-883-7154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT637
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: