Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 45304-020 | WI |
N | 207QA0401X | Family Doctor - Addiction Medicine | 45304-020 | WI |
NPI | 1720007271 |
---|---|
Provider Name | Mr. Timothy William Allen |
First Address | Cudahy, WI 53110-1360 |
Second Address | Cudahy, WI 53110-1360 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/07/2006 |
Last Update Date | 21/03/2020 |