Provider Demographics
NPI:1255324885
Name:VANNATTA, TIMOTHY L (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:L
Last Name:VANNATTA
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 1:21840 NORMANDIE AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90502-2047
Mailing Address - Country:US
Mailing Address - Phone:310-222-5026
Mailing Address - Fax:
Practice Address - Street 1:1000 W CARSON ST
Practice Address - Street 2:BOX 42
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2004
Practice Address - Country:US
Practice Address - Phone:310-222-5026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG87765208G00000X
CAG88765208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0207605Medicaid
IA17556OtherWELLMARK BCBS
IA17556OtherWELLMARK BCBS
IAI9968Medicare ID - Type Unspecified
E46206Medicare UPIN
IA0207605Medicaid