Provider Demographics
NPI:1295732774
Name:MOONEY, TIMOTHY J (MD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:J
Last Name:MOONEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:TIMOTHY
Other - Middle Name:J
Other - Last Name:MOONEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:807 EDEN OAKS DR
Mailing Address - Street 2:
Mailing Address - City:PONCHATOULA
Mailing Address - State:LA
Mailing Address - Zip Code:70454-6389
Mailing Address - Country:US
Mailing Address - Phone:985-345-2555
Mailing Address - Fax:985-345-2837
Practice Address - Street 1:42333 DELUXE PLZ
Practice Address - Street 2:SUITE 7
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1239
Practice Address - Country:US
Practice Address - Phone:985-345-2555
Practice Address - Fax:985-345-2837
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.019931207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1985368Medicaid
LAF27963Medicare UPIN
LA1985368Medicaid