Provider Demographics
NPI:1730678210
Name:DODD, TIMOTHY WILLIAM SR
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:WILLIAM
Last Name:DODD
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 NEWPORT BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:EAST MORICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11940-1566
Mailing Address - Country:US
Mailing Address - Phone:631-680-0728
Mailing Address - Fax:
Practice Address - Street 1:10 NEWPORT BEACH BLVD
Practice Address - Street 2:
Practice Address - City:EAST MORICHES
Practice Address - State:NY
Practice Address - Zip Code:11940-1566
Practice Address - Country:US
Practice Address - Phone:631-761-2504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-09
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY584536163WP0809X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult