Healthcare Provider Details

I. General information

NPI: 1316169238
Provider Name (Legal Business Name): TIMOTHY O'CONNOR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 07/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVE BOX 655
ROCHESTER NY
14642-8655
US

IV. Provider business mailing address

601 ELMWOOD AVE BOX 655
ROCHESTER NY
14642-8655
US

V. Phone/Fax

Practice location:
  • Phone: 585-341-3015
  • Fax:
Mailing address:
  • Phone: 585-341-3015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number144070
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMT189123
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD436616
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number268288
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: