Basic Information
| Provider Information | |||||||||
| NPI: | 1750372355 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAYHEW | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 160 | ||||||||
| Address2: | |||||||||
| City: | SHIPROCK | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874200160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053686020 | ||||||||
| FaxNumber: | 5053686431 | ||||||||
| Practice Location | |||||||||
| Address1: | US HWY 491 N | ||||||||
| Address2: | |||||||||
| City: | SHIPROCK | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053686020 | ||||||||
| FaxNumber: | 5053686431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 25931 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 04386370 | 05 | CO | MEDICAID | Q9966 | 05 | NM | MEDICAID | 429060 | 05 | AZ | MEDICAID |