Healthcare Provider Details

I. General information

NPI: 1588733604
Provider Name (Legal Business Name): TIMOTHY MARK KOBERNIK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 04/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MADIGAN ARMY MEDICAL CTR 9040 REID ST. ATTN MCHJ-QCR
TACOMA WA
98431-1100
US

IV. Provider business mailing address

MADIGAN ARMY MEDICAL CTR 9040 REID ST. ATTN MCHJ-QCR
TACOMA WA
98431-1100
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-6033
  • Fax: 253-968-2826
Mailing address:
  • Phone: 253-968-6033
  • Fax: 253-968-2826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOP00002182
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: