Provider Demographics
NPI:1144211418
Name:CUSTER, TIMOTHY JOHN (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JOHN
Last Name:CUSTER
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 1:2405 N COLUMBUS ST
Mailing Address - Street 2:SUITE 250
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-8185
Mailing Address - Country:US
Mailing Address - Phone:740-654-6213
Mailing Address - Fax:740-654-3346
Practice Address - Street 1:2405 N COLUMBUS ST
Practice Address - Street 2:SUITE 250
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-8185
Practice Address - Country:US
Practice Address - Phone:740-654-6213
Practice Address - Fax:740-654-3346
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35074468208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2232695Medicaid
OHCU4046633Medicare PIN
OH2232695Medicaid
H34496Medicare UPIN