Provider Demographics
NPI:1609826650
Name:PISTOCCO, TIMOTHY BRUCE (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:BRUCE
Last Name:PISTOCCO
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:PO BOX 507
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79101
Mailing Address - Country:US
Mailing Address - Phone:806-355-9595
Mailing Address - Fax:806-353-1589
Practice Address - Street 1:1501 S COULTER ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1770
Practice Address - Country:US
Practice Address - Phone:806-354-1000
Practice Address - Fax:806-354-1200
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH4617207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX128918305Medicaid
GA050045042OtherRR MEDICARE
TX128918305Medicaid