Provider Demographics
NPI:1134128424
Name:OLTERSDORF, TIMOTHY P (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:P
Last Name:OLTERSDORF
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 1:1101 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4377
Mailing Address - Country:US
Mailing Address - Phone:817-336-4638
Mailing Address - Fax:817-870-0278
Practice Address - Street 1:1101 6TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4377
Practice Address - Country:US
Practice Address - Phone:817-336-4638
Practice Address - Fax:817-870-0278
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF89732085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX124446902Medicaid
TX80R346Medicare ID - Type Unspecified
TX124446902Medicaid