Provider Demographics
NPI:1376500298
Name:SMULLEN, TIMOTHY L (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:L
Last Name:SMULLEN
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:DEPT L-647
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43260-0001
Mailing Address - Country:US
Mailing Address - Phone:866-287-0568
Mailing Address - Fax:
Practice Address - Street 1:793 W STATE ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43222-1551
Practice Address - Country:US
Practice Address - Phone:614-234-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350881082085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2670748Medicaid
OH2670748Medicaid
OHSM4189311Medicare PIN