Provider Demographics
NPI:1225019425
Name:OLTHOFF, TIMOTHY D (DO)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:D
Last Name:OLTHOFF
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10835 N 25TH AVE
Mailing Address - Street 2:STE 240
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-3458
Mailing Address - Country:US
Mailing Address - Phone:219-464-4891
Mailing Address - Fax:219-464-1873
Practice Address - Street 1:810 WHIPPLE ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1606
Practice Address - Country:US
Practice Address - Phone:928-771-7577
Practice Address - Fax:928-458-2080
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN020029002085R0202X
AZ0061902085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00324999OtherRR MEDICARE
IN200521590Medicaid
INP00324999OtherRR MEDICARE
IN200521590Medicaid