Healthcare Provider Details

I. General information

NPI: 1316968985
Provider Name (Legal Business Name): TIMOTHY LOUIS GENDRON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 06/27/2024
Certification Date: 06/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 THOMPSON AVE E STE 150
WEST ST PAUL MN
55118-3238
US

IV. Provider business mailing address

4240 PARK GLEN RD
ST LOUIS PARK MN
55416-5427
US

V. Phone/Fax

Practice location:
  • Phone: 651-450-0860
  • Fax: 651-450-0759
Mailing address:
  • Phone: 612-925-6033
  • Fax: 612-925-8496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD10047
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number205100
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number56058
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number69137-20
License Number StateWI
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberC173229
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: