Provider Demographics
NPI:1396832887
Name:EISENHUT, TIMOTHY MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:MICHAEL
Last Name:EISENHUT
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 1:6640 PARKDALE PLACE
Mailing Address - Street 2:SUITE U
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-4698
Mailing Address - Country:US
Mailing Address - Phone:317-291-5190
Mailing Address - Fax:317-291-1510
Practice Address - Street 1:6640 PARKDALE PLACE
Practice Address - Street 2:SUITE U
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-4698
Practice Address - Country:US
Practice Address - Phone:317-291-5190
Practice Address - Fax:317-291-1510
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01033758A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100228800Medicaid
000000087000OtherANTHEM