Provider Demographics
NPI:1679559355
Name:DEACONSON, TIMOTHY (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:DEACONSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 MARSH ST
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-5294
Mailing Address - Country:US
Mailing Address - Phone:507-389-4700
Mailing Address - Fax:
Practice Address - Street 1:1025 MARSH ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-4752
Practice Address - Country:US
Practice Address - Phone:507-625-4031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47404208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNG84624Medicare UPIN
MN020002066Medicare ID - Type Unspecified