=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508979246
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES R TIMKO M.A.,CCC-A
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2006
-----------------------------------------------------
Last Update Date | 12/30/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 844 N STONE ST STE 206
-----------------------------------------------------
City | DELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32720-3208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-736-7192
-----------------------------------------------------
Fax | 386-736-8520
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 844 N STONE ST STE 206
-----------------------------------------------------
City | DELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32720-3208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-736-7192
-----------------------------------------------------
Fax | 386-736-8520
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number | AY393
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------