Provider Demographics
NPI:1376501734
Name:STORER, TIMOTHY J (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:STORER
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:L-3549
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:740-383-7927
Mailing Address - Fax:740-383-7942
Practice Address - Street 1:12 LEXINGTON BLVD
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-4071
Practice Address - Country:US
Practice Address - Phone:740-362-0794
Practice Address - Fax:740-368-4118
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350791535207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2248946Medicaid
7007266OtherAETNA
353077OtherSUMITTER NO
0300610OtherUHC
OH2248946Medicaid
OH000000195086OtherANTHEM
0300610OtherUHC
353077OtherSUMITTER NO
OH4046055Medicare ID - Type Unspecified
OH000000195086OtherANTHEM
OHH161040Medicare PIN
311098079OtherTAXID PHYSICIANS AND NONP
OH4046055Medicare ID - Type Unspecified
OHH161040Medicare PIN
311098079OtherPPO NEXT