Provider Demographics
NPI:1043401292
Name:DEHART, TIMOTHY SHAWN (CSFA)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:SHAWN
Last Name:DEHART
Suffix:
Gender:M
Credentials:CSFA
Other - Prefix:MR
Other - First Name:TIMOTHY
Other - Middle Name:SHAWN
Other - Last Name:DEHART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CERTIFIED FIRST ASSI
Mailing Address - Street 1:204 DEERCREEK LN
Mailing Address - Street 2:
Mailing Address - City:LEANDER
Mailing Address - State:TX
Mailing Address - Zip Code:78641-7819
Mailing Address - Country:US
Mailing Address - Phone:512-557-6433
Mailing Address - Fax:512-337-3750
Practice Address - Street 1:204 DEERCREEK LANE
Practice Address - Street 2:SUITE 1550
Practice Address - City:LEANDER
Practice Address - State:TX
Practice Address - Zip Code:78641
Practice Address - Country:US
Practice Address - Phone:512-557-6433
Practice Address - Fax:512-337-3750
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-05
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX87458246ZC0007X, 246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX20-2099608OtherEIN