Provider Demographics
NPI:1376731885
Name:SENTHAVISOUK, TIM (NP)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:
Last Name:SENTHAVISOUK
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1239
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48099-1239
Mailing Address - Country:US
Mailing Address - Phone:248-824-6600
Mailing Address - Fax:248-324-1477
Practice Address - Street 1:4800 FREDERICKSBURG RD
Practice Address - Street 2:SUITE 127
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3628
Practice Address - Country:US
Practice Address - Phone:210-733-5072
Practice Address - Fax:210-733-8649
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX775309363LF0000X, 363L00000X
CANP 16316363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0930196740Medicaid
CA0930196740Medicaid
CA0930196740Medicare Oscar/Certification
CA0930196740Medicare PIN
CA0930196740Medicare UPIN